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Based on observation, staff interview, and policy and procedure review the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection for one (1) of two (2) days of survey.

Findings Include:

Observation of Emergency Department, Trauma Room #2 on 02/08/2023 at 11:55 a.m., with the Nurse Manager revealed an unknown substance dried on the underside of the mattress.

During the facility tour of the Medical Surgical Unit on 02/08/2023 at 2:30 p.m., accompanied by the Nurse Manager, four (4) of four (4) randomly sampled Patient Rooms #134, #139, #143, and #144, were found with unknown substance on the bed side rails, underside of mattresses, and electrical cords in rooms labeled as cleaned.

An interview with the Nurse Manager on 02/08/2023 at 11:55 a.m. confirmed unknown substance dried on the underside of the mattress in Emergency Department Trauma Room #2.

An interview with the Nurse Manger on 02/08/2023 at 2:30 p.m., confirmed an unknown substance dried on the underside of the mattresses, side rails, and electrical cords on four (4) of four (4) beds, rooms #134, #139, #143, and #144 on the Medical Surgical Unit.

Review of the facility's Policy titled, "Terminal room cleaning", effective 01/01/2019, " ...the procedure for patient room cleaning after discharge ...clean and disinfect ...raise foot and head of bed before starting ...clean hand rails ...clean mattress, head board, and foot board ...".

Review of the facility's Policy titled, "Infection Control in Environmental Services", revision date 04/17/2019, " ...the hospital contributes to the infection control effort in the hospital ...Sanitation within the hospital environment depends upon cleaning thoroughness...".

During exit conference on 02/09/2023 at 3:00 p.m. with Human Resource Manager, Director of Nursing, Risk/Quality Manager and CEO survey findings were discussed and no further documentation was submitted for review.