Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0070 (Restrictions on the use of portable space heaters.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0074 (Restrictions on the use of flammable curtains.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 28, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0022 (Signs that state that exit doors are to be kept closed.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0046 (Emergency lighting that can last at least 1 1/2 hours.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Fire Safety
Deficiency: K0141 (No-smoking signs where oxygen is used.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, May 25, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0334 (Develop policies and procedures for influenza and pneumococcal immunizations.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0353 (Have enough nurses to care for every resident in a way that maximizes the resident's well being.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0322 (Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0364 (Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right tempe)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, July 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0363 (Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nut)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0502 (Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0242 (Ensure residents have the right to have a choice over activities, their schedules, and health care a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0325 (Ensure residents maintain acceptable nutritional status.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, May 12, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, March 27, 2014
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, January 7, 2014
Survey Type: Health
Deficiency: F0242 (Ensure residents have the right to have a choice over activities, their schedules, and health care a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, February 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, January 7, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, February 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, December 3, 2013
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, January 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 26, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 26, 2013
Survey Type: Health
Deficiency: F0166 (Try to resolve each resident's complaints quickly.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 26, 2013
Survey Type: Health
Deficiency: F0205 (Tell the resident or the resident’s representative in writing how long the nursing home will hold th)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 12, 2013
Survey Type: Health
Deficiency: F0388 (Make sure that all required doctor visits are made personally.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 12, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 12, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 12, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, May 15, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0223 (Protect each resident from all abuse, physical punishment, and involuntary separation from others.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, June 4, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0242 (Ensure residents have the right to have a choice over activities, their schedules, and health care a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0276 (Assure that each resident’s assessment is updated at least once every 3 months.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0364 (Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right tempe)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0388 (Make sure that all required doctor visits are made personally.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, July 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0412 (Provide or obtain dental services for each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 24, 2013
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, October 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0073 (Restrictions on the use of highly flammable decorations.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0043 (Rooms that can be unlocked from inside without a key.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0020 (Proper stairway enclosures and vertical shafts.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 23, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, May 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 10, 2012
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, July 10, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 13, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, June 13, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 25, 2012
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: H
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0141 (No-smoking signs where oxygen is used.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0505 (Quickly tell the resident's doctor the results of laboratory tests.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0467 (Have enough outside ventilation via a window or mechanical ventilation, or both.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0490 (Make sure that the facility is administered in an acceptable way that maintains the well-being of ea)
Scope Severity Code: H
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0469 (Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0325 (Ensure residents maintain acceptable nutritional status.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: H
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 9, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, February 29, 2012
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 10, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)