Cycle 1
Health 2025-02-06 · Fire 2025-02-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Danvers, MA
Hunt Nursing & Rehab Center
3-star overall rating with 3-star inspections with $10,517 in total fines with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
90 Lindall Street, Danvers, MA
(978) 621-9757
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Integritus Healthcare
Operator or chain grouping
Approved since
1998-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,660
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.53
Baseline 21.35% · Performance 19.33% · Measure score 4.53 · Achievement 4.53 · Improvement 4.17
Healthcare-associated infections
3.69
Baseline 6.78% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
1.08
Baseline 57.89% · Performance 59.26% · Measure score 1.08 · Achievement 1.08 · Improvement 0
Adjusted total nurse staffing
2.34
Baseline 3.77 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 12.78% · Lower 95% interval 8.35% |
| Discharge to community | 37.67% |
50.57%
12.9 pts worse
|
Worse than the National Rate · Eligible stays 73 · Observed rate 26.03% · Lower 95% interval 25.76% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.82% |
95.27%
3.5 pts better
|
Numerator 84 · Denominator 85 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 85 |
| Discharge self-care score | 25.76% |
53.69%
27.9 pts worse
|
Numerator 17 · Denominator 66 |
| Discharge mobility score | 31.82% |
50.94%
19.1 pts worse
|
Numerator 21 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 4.71% |
2.29%
2.4 pts worse
|
Numerator 4 · Denominator 85 · Adjusted rate 4.24% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 6.33% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 6.8% |
8.2%
1.4 pts worse
|
Numerator 7 · Denominator 103 |
| Staff flu vaccination coverage | 42.11% |
42%
0.1 pts better
|
Numerator 32 · Denominator 76 |
| Discharge function score | 36.36% |
56.45%
20.1 pts worse
|
Numerator 24 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 60% |
25.2%
34.8 pts better
|
Numerator 24 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
92.2%
1.5 pts worse
|
93.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 96.2% · Q3 92.2% · Q4 80.0% · 4Q avg 90.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.8%
3.3 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.5%
0.9 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.8% · Q3 2.0% · Q4 1.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.4% |
12.0%
11.4 pts worse
|
11.4%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 21.2% · Q3 35.0% · Q4 29.2% · 4Q avg 23.4% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.2%
2.6 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 1.1% · Q4 2.2% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
19.2%
7.8 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 11.8% · Q3 7.0% · Q4 9.7% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
22.5%
2 pts better
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 17.9% · Q3 13.6% · Q4 15.4% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.7% |
17.7%
4 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 10.4% · Q3 18.4% · Q4 6.6% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
17.6%
3.9 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 14.9% · Q3 14.3% · Q4 15.5% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.0%
0.1 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.9% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.0%
About the same
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 3.0% · Q4 3.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
21.7%
0.8 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 19.4% · Q3 23.7% · Q4 29.0% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.6%
1.1 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.5% · Q3 3.3% · Q4 3.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
77.1%
9.5 pts better
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 87.9% · Q3 81.5% · Q4 75.8% · 4Q avg 86.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.8%
3.6 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 9.4% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.4% |
77.7%
3.7 pts better
|
79.7%
1.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.8%
7.5 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 17.0% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
13 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-29 · Fire 2022-12-29
12 health deficiencies
Top issue: Resident Rights (5 deficiencies)
7 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-31
F · Potential for more than minimal harm
2025-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-31
E · Potential for more than minimal harm
2025-02-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-02-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-03-31
D · Potential for more than minimal harm
2022-12-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-12-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-02-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-11-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-15
G · Actual harm
2024-04-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-20
G · Actual harm
2024-04-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
F · Potential for more than minimal harm
2024-02-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-20
D · Potential for more than minimal harm
2023-05-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-06
D · Potential for more than minimal harm
2023-05-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-06
D · Potential for more than minimal harm
2022-12-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-02-09
D · Potential for more than minimal harm
2022-12-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
$10,517
2024-04-16
Fine
Fine · fine $10,517
Fine
Ownership
Fairview Extended Care Services Inc
5% Or Greater Direct Ownership Interest · Organization
Fairview Extended Care Services Inc
Operational/Managerial Control · Organization
Gingras, Marcie Jo
Operational/Managerial Control · Individual
Gingras, Marcie Jo
Corporate Officer · Individual
Integritus Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Integritus Healthcare Inc
5% Or Greater Security Interest · Organization
Integritus Healthcare Management Services Inc
5% Or Greater Indirect Ownership Interest · Organization
Integritus Healthcare Management Services Inc
Operational/Managerial Control · Organization
Jones, William
Operational/Managerial Control · Individual
Jones, William
Corporate Director · Individual
Jones, William
Corporate Officer · Individual
Poudel, Santosh
Operational/Managerial Control · Individual
Spittle, Sharon
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Twin Oaks Center
Danvers, MA
1-star overall rating with 1-star inspections with $141,733 in total fines with 19 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Brentwood Rehabilitation And Healthcare Ctr (The)
Danvers, MA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hathorne Hill Rehabilitation And Healthcare Center
Danvers, MA
4-star overall rating with 4-star inspections with $242,785 in total fines with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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