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Based on observation, review of documentation, and interviews with staff, it was determined that the facility failed to provide an acceptable level of safety and quality as patient rooms were visibly unsanitary.

Findings included:

Observation during a tour of the Neurology Department on 10/16/12 at approximately 10:35am, revealed visible dust on the white linen which was on the patient bed in room 267, dust on the high horizontal surfaces on the ledge above the head of the bed. As per the facility staff, the room had been cleaned and was ready for patient use. The facility had plans to admit a patient in room 267 while the surveyor was in the room. Staff members #6 and #7 were notified of the findings.

Review of facility policy entitled, "Discharge Room Cleaning" stated, "1. Remove trash and strip beds... 3. Use Virex ...to disinfect all surfaces. Move throughout the room in clockwise motion. 4. High dust and disinfect anything above 6 feet ...7. Using clean linen, make the bed."

It was confirmed by staff member #1, #3, and #6 on 10/16/12 at approximately 10:35am that room 267 was not cleaned according to facility policy and procedures. The staff members witnessed the visible dust on the linen and the dust on the high horizontal surfaces.

Based on interview with staff the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings included:

During tours of the facility, the following infection control issues were revealed:

Observation during a tour of the Emergency Department on 10/16/12 at approximately 10:05am in the company of staff member #1, #2, and other administrative staff members, revealed that the critical care room #1 had a reddish-brown substance on the handle of the bed. As per facility staff the room was cleaned and was available for patient use.

Further observation during a tour of the EEG Clinic in the company of staff member #1, #4 and other administrative staff members on 10/16/12 at approximately 11:20am revealed if a patient that is approximately 3 years of age presented to the EEG clinic, the staff would always use gloves because of the adhesive that was used and the staff having to leave the patient to wash the adhesive off the hands. Staff member #4 stated that 3 year old patients have a short attention span. When the surveyor asked if the staff used gloves with patients that are 7-8 years old, Staff member #4 stated "no." Staff member #4 mentioned that the 7-8 year old patients could sit long enough while the techs placed the electrodes on the head and washed the adhesive off the hands if needed. The staff failed to follow Universal Precautions.

In an in-person interview with staff member #1, #4 and other administrative staff members, on 10/16/2012 at approximately 11:20am, it was confirmed that the staff were not using gloves on a consistent basis. Staff member #1 confirmed that the staff member should be using gloves with all patients.