Oct 27, 2026
98 / 100
· 4 violations
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair.
Observed water stained ceiling tile in Plebotomy and black microbial growth in the restroom in radiology. Observed staining wall, need new paint in room 3 and 4 on 10th floor.
#10 · Handwashing facilities properly located and equipped
.1312 (d) Hand washing facilities shall be equipped with running water and a tempering device. Observed no disposable towels at handsink in soiled utility room and in nourishment area in Dickson Heart Unit. Observed no soap and paper towels available in soiled utility 8th floor, no soap in staff restroom 9th floor, no paper towel in soiled utility 10th floor, no paper towel on 9th floor nourishment area. Ensure to provide all hand washing supplies at all hand sink at all times.
#16 · Hot water between 105°F and 116°F −1.5
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities.
Observed hot water at 119F at nourishment area handsink in unit CURU. Observed hot water 84F in Adult ED major treatment room 13. Observed no water available in patient room #8619.
- Observed in children hospital no hot water at hand sink in soiled utility room 9th floor and 8th floor laundry room. Observed hot water measured between 79F -104F on 7th floor playroom, NPCN, 6th floor, 9th floor PICU, 8th floor playroom and nourishment room. Ensure to provide tempered water between 105F to 116 F at anytime.
Repeat.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed microwave in nourishment area in 5 tower and 11T with build up on ceiling. Observed spill on door in refrigerator in 10DE. Observed soiled/stained microwave/refrigerator in nourishment area on 10th, 11th family snack room.
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Jun 16, 2026
99 / 100
· 7 violations
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed scuffed walls in patient room #11913, #10620, LCH 11th floor room 1101 and room 14 on LCH level 10. Observed stained ceiling tile in LCH soiled utility on Dialysis unit. Observed floor tile in need of repair in the closet in pathology. Observed water stained ceiling tile in the closet in phlebotomy.
#8 · Toilet rooms free of storage, handwash signs posted
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed extra shower chairs, toilet chairs, and other furniture stored in patient restroom on 3B.
#16 · Hot water between 105°F and 116°F
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at 84F in room 14 in LCH 10th floor. Observed hot water at 119F in mother baby unit. Observed hot water measured at 118F in Dickson Heart ICU unit, 117F in 5 tower, 120F in 6 Tower, 100F in restroom 6B. Provide tempered water between 105F -116F at anytime.
#26 · Premises properly maintained
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed debris and trash under temp lift in dumpster area.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed chair peeling in hall on 3K (tan). Observed shower chair in poor repair in need of replacing in patient room #11215. Observed closet hinge broken in 922. Observed couch and chair upholstery torn in Epilepsy room 4.
#38 · Food service equipment and utensils clean, good repair −0.5
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed build up in microwave and fridge drawer broken in 9 Tower nourishment room. Observed soiled microwave needs cleaning in 4 Tower nourishment
#43 · Food brought into the institution by employees or visitors of patients or residents properly stored, labeled and dated −0.5
.1321 (b) Food brought from home by employees or visitors of patients or residents shall be stored separately from the institution's food supply as described in rule .1321 (a). Such food shall be labeled with the name of the resident or employee that the food belongs to and the date the food was brought into the institution. Labeling as required by this Rule shall not be required for food items stored in employee-designated or individual residents' refrigerators or rooms.
- Observed patient food without date in refrigerator in CTICU, and Dickson Heart ICU. Ensure to completely label with name and date that food was brought in.
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Oct 30, 2025
98.5 / 100
· 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free −1
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged/cracked floor tiles in halls EVS overflow, 3T, 3B areas. Observed water stained ceiling tile in the pathology storage room. Replaced during the inspection. Observed corner guard in need of repair in cytology. Observed water stained ceiling tile in storage closet (04C112) in CT.
#2 · Walls and ceilings clean, good repair
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed minor chipping on wall outside dialysis bathroom. Observed wall damaged in need of repair in patient room (7205).
#7 · Facilities provided, accessible, clean, good repair
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair.- Observed slow draining at hallway sink across storage room 04T120, and sink in patient room 4927. Repair needed. Repeat.
#8 · Toilet rooms free of storage, handwash signs posted
.1312 (b) Bathrooms shall not be used for storage of items not currently in use. Observed several toilet chairs stored in hallway patient bathroom in 3B.
#26 · Premises properly maintained
.1316 (d) An institution's exterior premises, including parking lots, lawns, and walkways, and interior premises within the institution's building or buildings, shall be kept free of garbage, solid waste, yard trash, and pest harborages. Observed trash and debris around dumpsters in loading area.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed chair torn in 9504 and chairs torn in hall of 10B. Observed bedside table chipping in 10911; Observed couch cushion damaged in need of replacing; Observed pillows (not cases) stained in need of replacing in patient room (8908) Repeat.
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May 7, 2025
96.5 / 100
· 6 violations
#1 · Floors and carpets cleanable, clean, good repair; carpet odor free
NO POINTS DEDUCTED
1309 (a) and (b) The floors in an institution shall be made of smooth, non-absorbent materials and shall be kept clean and in good repair. When carpet is present, it must be kept clean, odor free, and in good repair. Observed damaged flooring in hall outside of 9903.
#2 · Walls and ceilings clean, good repair
REPEAT
NO POINTS DEDUCTED
.1310 (a) The interior walls of the institution, including doors, windows and window trim, and ceilings, shall be kept clean and in good repair. Observed scuffed walls and damaged baseboards throughout downstairs loading dock area and storage areas; Observed minor cracking of paint next to bathroom sink in 10B. (No points deducted due to improvement noted.
#7 · Facilities provided, accessible, clean, good repair
NO POINTS DEDUCTED
.1312 (a) All institutions shall provide toilet, handwashing, and bathing facilities that are available for use by residents and staff. These facilities shall be kept clean and in good repair. Observed green residue on hand sink faucet in 10909. Observed leak from piping at hand sink in (7B) nourishment room in need of repair; Observed slow drain inside room #8410
#16 · Hot water between 105°F and 116°F −3
REPEAT
.1313 (d) Institutions shall provide water heating facilities. Hot and cold running water under pressure shall be provided to carry out all operations. Hot water shall be provided at temperatures between 105 degrees Fahrenheit and 116 degrees Fahrenheit at handwashing and bathing facilities. Observed hot water at in LCH dialysis unit at 95F and at 102F in unit 7100. Observed hot water only reach 81F in CT; Observed 3rd floor room #16 water observed at 84F.
Observed water temperature measured at 119F in 7707 DHU; 103F in 6A nurse station, soiled utility, and room 6115; Observe 92F in shower room 6 CD-ADTU; 81F in 6B room 6207. 95F in 6B room 6211; 118F 6HCTICU, and patient restroom on the hall. (Note) DHU and 6 Tower having discolored / rusty water at all hand sinks.
#32 · Furnishings clean and in good repair; mattresses dry, clean, good repair −0.5
REPEAT
.1319 (a) Furnishings in an institution, including furniture, curtains, rugs, and blinds, shall be kept clean and in good repair. Mattresses shall be kept clean, dry, and in good repair. Observed damaged cabinet in Nourishment in 9A. Observed damaged cabinet drawers in 10A. Observed chair cushion ripped inside room #8203 in need of repair / replaced; Observed counter top with old spilled debris accumulated (8DE) Nourishment room.
#38 · Food service equipment and utensils clean, good repair
NO POINTS DEDUCTED
.1320 (a) All food service equipment and utensils shall be kept clean and in good repair. Observed spill in 9E nourishment freezer and 10DE nourishment 2 refrigerator
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Oct 29, 2024
97.5 / 100
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Apr 9, 2024
97 / 100
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Oct 11, 2023
97.5 / 100
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Apr 19, 2023
98.5 / 100
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Sep 27, 2022
97.5 / 100
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Apr 6, 2022
97 / 100
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Aug 11, 2021
97 / 100
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Oct 28, 2020
97 / 100
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Feb 27, 2020
96 / 100
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Sep 12, 2019
96.5 / 100
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Mar 19, 2019
95 / 100
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Oct 11, 2018
94 / 100
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Apr 17, 2018
95 / 100
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Dec 13, 2017
93.5 / 100
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May 16, 2017
95.5 / 100
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Aug 30, 2016
95.5 / 100
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Apr 20, 2016
94.5 / 100
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Nov 3, 2015
95 / 100
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Jun 3, 2015
97 / 100
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Dec 17, 2014
97.5 / 100
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Apr 8, 2014
no score published
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Apr 8, 2014
96.5 / 100
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Nov 20, 2013
95.5 / 100
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