Survey Date: Friday, July 11, 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: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
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: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
Survey Type: Health
Deficiency: F0164 (Keep residents' personal and medical records private and confidential.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
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: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
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: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 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: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Friday, July 11, 2014
Survey Type: Health
Deficiency: F0368 (1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a sn)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0143 (Proper fire barriers, ventilation and signs for the transfilling of oxygen.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 10, 2014
Survey Type: Fire Safety
Deficiency: K0075 (Properly sized and located linen or trash receptacles.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, July 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: Sunday, August 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
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: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
Survey Type: Fire Safety
Deficiency: K0048 (A written emergency evacuation plan.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 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: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
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, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 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: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 2013
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: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 22, 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: Monday, September 23, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0222 (Keep each resident free from drugs that restrain them, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0248 (Provide activities to meet the interests and needs of each resident.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
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, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0463 (Make sure that a working call system is available in each resident's room or bathroom and bathing ar)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0456 (Keep all essential equipment working safely.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 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: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, August 1, 2013
Survey Type: Health
Deficiency: F0468 (Put firmly secured handrails on each side of hallways.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, August 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Friday, March 29, 2013
Survey Type: Health
Deficiency: F0224 (Protect each resident from mistreatment, neglect and misappropriation of personal property.)
Scope Severity Code: J
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Friday, March 29, 2013
Survey Type: Health
Deficiency: F0223 (Protect each resident from all abuse, physical punishment, and involuntary separation from others.)
Scope Severity Code: J
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Friday, March 29, 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: J
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, August 28, 2012
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: Wednesday, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, August 28, 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: Wednesday, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, August 28, 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, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, August 28, 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: Wednesday, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, August 28, 2012
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: Wednesday, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, August 28, 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: Wednesday, September 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, August 22, 2012
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: Thursday, November 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, August 22, 2012
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, November 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, August 22, 2012
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: Thursday, November 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, August 22, 2012
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, November 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, June 19, 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: Thursday, June 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, June 19, 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: Thursday, June 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)
Survey Date: Monday, November 14, 2011
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 9, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)