Cycle 1
Health 2025-02-21 · Fire 2025-02-21
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lompoc, CA
Lompoc Skilled Nursing & Rehabilitation Center
4-star overall rating with 4-star inspections with $4,893 in total fines with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1428 West North Avenue, Lompoc, CA
(805) 735-4010
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Generations Healthcare
Operator or chain grouping
Approved since
2005-12-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 4 overall / 3 health / 3 staffing / 4 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
0.48
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,000
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9999
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.98
Baseline 18.07% · Performance 19.59% · Measure score 3.98 · Achievement 3.98 · Improvement 0
Healthcare-associated infections
2.82
Baseline 6.96% · Performance 6.99% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Total nurse turnover
7.50
Baseline 39.62% · Performance 33.04% · Measure score 7.50 · Achievement 7.50 · Improvement 3.96
Adjusted total nurse staffing
4.30
Baseline 4.20 hours · Performance 4.30 hours · Measure score 4.30 · Achievement 4.30 · Improvement 0.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 310 · Observed rate 8.06% · Lower 95% interval 7.58% |
| Discharge to community | 57.95% |
50.57%
7.4 pts better
|
Better than the National Rate · Eligible stays 324 · Observed rate 54.94% · Lower 95% interval 53.03% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.57% |
95.27%
4.3 pts better
|
Numerator 229 · Denominator 230 |
| Falls with major injury | 2.61% |
0.77%
1.8 pts worse
|
Numerator 6 · Denominator 230 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 67 · Denominator 134 |
| Discharge mobility score | 51.49% |
50.94%
0.6 pts better
|
Numerator 69 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 0.87% |
2.29%
1.4 pts better
|
Numerator 2 · Denominator 230 · Adjusted rate 0.82% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 5.93% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 2.11% |
8.2%
6.1 pts worse
|
Numerator 4 · Denominator 190 |
| Staff flu vaccination coverage | 68.95% |
42%
27 pts better
|
Numerator 131 · Denominator 190 |
| Discharge function score | 61.19% |
56.45%
4.7 pts better
|
Numerator 82 · Denominator 134 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 155 · Denominator 155 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 25.89% |
25.2%
0.7 pts better
|
Numerator 29 · Denominator 112 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
98.2%
0.8 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
1.6%
1 pts worse
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.3% · Q3 2.3% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 2.6% |
4.1%
1.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 5.4% · Q4 1.3% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
13.7%
4.7 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 17.2% · Q3 20.5% · Q4 19.7% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
14.2%
3.9 pts worse
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.4% · Q3 16.4% · Q4 19.7% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 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 | 7.9% |
11.0%
3.1 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.7% · Q3 6.6% · Q4 8.7% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.9% · Q3 7.8% · Q4 8.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.0%
0.3 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.2%
2.1 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 3.7% · Q4 7.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.8% |
10.9%
5.1 pts better
|
19.8%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.8% · Q3 8.4% · Q4 5.9% · 4Q avg 5.8% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.7%
0.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.0% · Q3 5.2% · Q4 4.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.0%
3.9 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.6% · Q3 97.7% · Q4 96.2% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.2% |
11.2%
9 pts worse
|
12.0%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 20.3% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 4.4% · Q4 2.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
93.2%
2.2 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
23.2%
6.4 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 26.4% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-18 · Fire 2023-08-18
9 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
11 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-02-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-02-21
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-07
C · Minimal harm
2025-02-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-05
E · Potential for more than minimal harm
2023-08-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-08-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-18
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-18
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-09-06
E · Potential for more than minimal harm
2019-10-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-27
E · Potential for more than minimal harm
2019-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-11-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-02-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-21
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 2025-03-20
D · Potential for more than minimal harm
2025-02-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-20
D · Potential for more than minimal harm
2025-02-21
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 2025-03-20
D · Potential for more than minimal harm
2025-02-21
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 2025-03-20
D · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-12-06
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 2025-01-07
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-10-03
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 2023-10-18
E · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
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 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-14
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 2023-08-19
D · Potential for more than minimal harm
2023-08-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-19
D · Potential for more than minimal harm
2023-05-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-10
D · Potential for more than minimal harm
2023-03-16
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 2023-03-24
F · Potential for more than minimal harm
2019-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-11
D · Potential for more than minimal harm
2019-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-29
D · Potential for more than minimal harm
2019-10-10
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 2019-11-10
D · Potential for more than minimal harm
2019-10-10
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 2019-10-10
D · Potential for more than minimal harm
2019-10-10
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-11-11
Penalties and ownership
What sits behind the stars
$1,748
2023-09-18
Fine
Fine · fine $1,748
Fine
$3,145
2023-08-28
Fine
Fine · fine $3,145
Fine
Ownership
Smith, Fred
5% Or Greater Indirect Ownership Interest · Individual
Bmo Bank National Association
5% Or Greater Security Interest · Organization
Hall, Mark
W-2 Managing Employee · Individual
Life Generations Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Life Generations Healthcare, LLC
Operational/Managerial Control · Organization
Mastrocola, Lois
5% Or Greater Direct Ownership Interest · Individual
Mastrocola, Lois
Corporate Officer · Individual
Olds, Thomas
5% Or Greater Direct Ownership Interest · Individual
Olds, Thomas
Corporate Officer · Individual
Nearby options
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Lompoc Valley Medical Center Comprehensive Care Ce
Lompoc, CA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Atterdag Care Center
Solvang, CA
5-star overall rating with 4-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Santa Maria Post Acute
Santa Maria, CA
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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