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Based on review of logs and interview, it was determined that the facility's operating rooms were not always in acceptable range for temperature and humidity.

Findings were:

According to an article entitled "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015" it was stated in part: "Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is "confusion" from ESD pulses. And, in an environment where humidity is low, a person can more easily become "charged" and receive an electrostatic shock when coming in contact with medical equipment."

Per guidance from OSHA provided by the facility "ORs must be designed to provide a space relative humidity (RH) of 20 to 60 percent, and a space temperature of 68 to 75 degrees F. However, many surgeons prefer a space temperature below 68 degrees F."

Tour of the OR area on 6/29/22 found the following:

* An unworking temperature/humidity gauge was found in OR #2. A working gauge was brought into the room and read the temperature as 68.5 degrees and the humidity at 66%.
* Logs were reviewed for the months of January 2022 through June 2022. Temperature and humidity were not checked daily. (Per CNO, temperature and humidity were only checked when procedures were to be done that day.) Humidity was frequently above 60%. There were no temperature/humidity parameters on the log, nor was their instruction on what to do/who to report to when temperature/humidity were out of range.

The above temperature/ humidity concerns were verified by the CFO/CNO on 6/29/22.

Based on observation and interview, it was determined that the facility did not always practice effective infection control.

Findings were:

In an article published by Spectrum Health in July 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

901.11 Equipment and Utensils Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils."

Tour of the facility on June 28, 2022 revealed the following infection control issues:

* Dust on top of the oven under the hood vent in the kitchen.
* Stacked wet dishes were also found in the kitchen which could lead to the growth of microorganisms.
* In the clean supply areas of the hospital including Central Supply, the ED Supply room and the Pharmacy, shipping boxes were stored amongst clean supplies which could cause cross contamination.
* The patient nutrition room had a dirty microwave and bugs in the fluorescent lighting fixture. Under the sink were rust and stains along with a discarded vent cover.
* The IV room also had rust and stains under the sink.
* ED Bay #1 had dust on high horizontal surfaces such as the surgical lamp and the medical monitor which revealed inadequate cleaning of the area.

Tour of the OR area on 6/29/22 revealed 2 rusted IV ploes in OR 1. One of the IV poles was missing a wheel--making it unusable.

The above issues were confirmed by the CFO/CNO on 6/28/22 and 6/29/22.