Cycle 1
Health 2024-05-16 · Fire 2024-05-16
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Loveland, CO
North Shore Health & Rehab Facility
4-star overall rating with 4-star inspections with $4,233 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1365 W 29th St, Loveland, CO
(970) 667-6111
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Columbine Health Systems
Operator or chain grouping
Approved since
1975-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 5 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
1.10
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,679
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.30
Composite VBP score used to determine payment impact.
Payment multiplier
1.0020
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.08
Baseline 19.98% · Performance 19.54% · Measure score 4.08 · Achievement 4.08 · Improvement 0.98
Healthcare-associated infections
6.56
Baseline 4.36% · Performance 5.88% · Measure score 6.56 · Achievement 6.56 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.86
Baseline 4.32 hours · Performance 4.18 hours · Measure score 3.86 · Achievement 3.86 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.54% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 6.29% · Lower 95% interval 6.97% |
| Discharge to community | 64.34% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 124 · Observed rate 66.13% · Lower 95% interval 55.97% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.73% |
95.27%
2.5 pts better
|
Numerator 43 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 67.57% |
53.69%
13.9 pts better
|
Numerator 25 · Denominator 37 |
| Discharge mobility score | 51.35% |
50.94%
0.4 pts better
|
Numerator 19 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.88% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 1.79% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 146 |
| Staff flu vaccination coverage | 78.33% |
42%
36.3 pts better
|
Numerator 141 · Denominator 180 |
| Discharge function score | 48.65% |
56.45%
7.8 pts worse
|
Numerator 18 · Denominator 37 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 57.14% |
25.2%
31.9 pts better
|
Numerator 12 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.3
1.4 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 1.7 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
93.5%
0.3 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 91.2% · Q3 92.1% · Q4 95.1% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
94.7%
1.2 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.4%
0.3 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 3.2% · Q4 3.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.4% |
7.4%
3 pts worse
|
11.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.5% · Q3 6.9% · Q4 20.3% · 4Q avg 10.4% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.0%
3.5 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 11.5% · Q3 12.5% · Q4 6.0% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
11.2%
1.5 pts worse
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 11.3% · Q3 14.0% · Q4 16.0% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
20.6%
2 pts better
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 18.6% · Q3 23.3% · Q4 18.2% · 4Q avg 18.6% · 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 | 23.8% |
15.2%
8.6 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 18.9% · Q3 15.5% · Q4 30.8% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
14.6%
6.5 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 17.3% · Q3 16.7% · Q4 22.4% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
1.5%
3.2 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.5% · Q3 4.9% · Q4 3.3% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
22.4%
4.5 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 28.6% · Q3 40.3% · Q4 18.6% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.7%
0.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.2% · Q3 4.2% · Q4 1.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.7% |
76.4%
0.3 pts better
|
81.7%
5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.5% · Q2 69.1% · Q3 74.0% · Q4 85.1% · 4Q avg 76.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
12.8%
3.1 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 15.2% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 1.2% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
75.6%
0.6 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.2% |
20.3%
8.1 pts better
|
23.9%
11.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 13.0% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-10 · Fire 2020-03-10
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
23 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-03-05 · Fire 2019-03-05
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-27
F · Potential for more than minimal harm
2020-03-10
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2020-04-24
F · Potential for more than minimal harm
2020-03-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2020-04-24
F · Potential for more than minimal harm
2020-03-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-10-24
F · Potential for more than minimal harm
2020-03-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-10-24
E · Potential for more than minimal harm
2020-03-10
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 2020-10-28
E · Potential for more than minimal harm
2020-03-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-10-24
E · Potential for more than minimal harm
2020-03-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-10-24
E · Potential for more than minimal harm
2020-03-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-09-25
D · Potential for more than minimal harm
2020-03-10
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 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-10-24
D · Potential for more than minimal harm
2020-03-10
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2020-10-24
F · Potential for more than minimal harm
2019-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-04-01
F · Potential for more than minimal harm
2019-03-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-04-19
F · Potential for more than minimal harm
2019-03-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-01
E · Potential for more than minimal harm
2019-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-01
E · Potential for more than minimal harm
2019-03-05
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-04-22
D · Potential for more than minimal harm
2019-03-05
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 2019-03-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-06-06
E · Potential for more than minimal harm
2024-05-16
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 2024-06-07
D · Potential for more than minimal harm
2024-05-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-08
D · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
E · Potential for more than minimal harm
2023-06-26
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 2023-08-15
E · Potential for more than minimal harm
2023-06-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-06-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-06-26
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-09
F · Potential for more than minimal harm
2020-03-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-03-10
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-03-10
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 2020-04-30
D · Potential for more than minimal harm
2020-03-10
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2020-04-24
D · Potential for more than minimal harm
2020-03-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2020-04-30
D · Potential for more than minimal harm
2020-03-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-04-17
F · Potential for more than minimal harm
2019-03-05
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 2019-04-17
F · Potential for more than minimal harm
2019-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-10
D · Potential for more than minimal harm
2019-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-04-12
D · Potential for more than minimal harm
2019-03-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-04-12
D · Potential for more than minimal harm
2019-03-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-04-17
Penalties and ownership
What sits behind the stars
$4,233
2023-05-02
Fine
Fine · fine $4,233
Fine
Ownership
Wilson, John
5% Or Greater Direct Ownership Interest · Individual
Columbine Management Services Inc
Operational/Managerial Control · Organization
Fancher, Barry
Corporate Officer · Individual
Fancher, Barry
W-2 Managing Employee · Individual
Fasciano-Sager, Lauren
Corporate Officer · Individual
Fasciano-Sager, Lauren
W-2 Managing Employee · Individual
King, Jacqueline
Operational/Managerial Control · Individual
Koretke, Mary
W-2 Managing Employee · Individual
Moskowitz, Jay
Corporate Officer · Individual
Moskowitz, Jay
Contracted Managing Employee · Individual
Qp Health Care Services LLC
Operational/Managerial Control · Organization
Wilson, John
Corporate Director · Individual
Wilson, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Riverbend Health And Rehabilitation Center
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4-star overall rating with 4-star inspections with 3 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
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Loveland, CO
5-star overall rating with 4-star inspections with $7,544 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society -- Loveland Village
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4-star overall rating with 4-star inspections with $35,489 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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