Cycle 1
Health 2025-04-09 · Fire 2025-04-09
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Lawrence, MA
Royal Wood Mill Center
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
800 Essex Street, Lawrence, MA
(978) 686-2994
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Royal Health Group
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,826
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.41
Baseline 23.08% · Performance 37.50% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Adjusted total nurse staffing
0.57
Baseline 3.87 hours · Performance 3.24 hours · Measure score 0.57 · Achievement 0.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.15% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 13.85% · Lower 95% interval 8.01% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 2.29% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 54 |
| Staff flu vaccination coverage | 17.31% |
42%
24.7 pts worse
|
Numerator 9 · Denominator 52 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.5
0.7 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
92.2%
1.9 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 80.3% · Q2 96.9% · Q3 100.0% · Q4 100.0% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.8%
3.8 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.5%
1.9 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 79.7% |
12.0%
67.7 pts worse
|
11.4%
68.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 83.3% · Q3 75.4% · Q4 82.4% · 4Q avg 79.7% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.2%
1.8 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 3.2% · Q3 1.7% · Q4 1.9% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.3% |
19.2%
5.1 pts worse
|
19.6%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.4% · Q3 23.0% · Q4 23.6% · 4Q avg 24.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 58.0% |
22.5%
35.5 pts worse
|
16.7%
41.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.4% · Q2 60.6% · Q3 58.3% · Q4 53.3% · 4Q avg 58.0% · 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 | 28.7% |
17.7%
11 pts worse
|
16.3%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.8% · Q3 44.4% · Q4 17.2% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
17.6%
11.7 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 21.8% · Q3 40.7% · Q4 28.6% · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
2.0%
3.6 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.9% · Q3 6.5% · Q4 5.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
21.7%
8.3 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 26.2% · Q3 19.8% · Q4 45.2% · 4Q avg 30.0% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.6%
1.6 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.7% · Q3 3.0% · Q4 3.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.3% |
77.1%
2.2 pts better
|
81.7%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.9% · Q2 79.4% · Q3 81.8% · Q4 85.7% · 4Q avg 79.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
11.8%
1.7 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 13.0% · Expected 14.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.3% |
77.7%
3.4 pts worse
|
79.7%
5.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
25.8%
4.1 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 34.8% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-22 · Fire 2024-04-22
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-03 · Fire 2023-03-03
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-09
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 2025-05-07
F · Potential for more than minimal harm
2025-04-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-07
D · Potential for more than minimal harm
2023-03-03
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 2023-03-25
D · Potential for more than minimal harm
2023-03-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-03-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-04-09
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 2025-05-02
E · Potential for more than minimal harm
2025-04-09
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 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
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 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
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 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
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 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
E · Potential for more than minimal harm
2024-04-22
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 2024-04-29
E · Potential for more than minimal harm
2024-04-22
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 2024-05-01
E · Potential for more than minimal harm
2024-04-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-22
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 2024-04-29
D · Potential for more than minimal harm
2024-04-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-22
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 2024-04-29
B · Minimal harm
2024-04-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-29
G · Actual harm
2024-04-09
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 2024-04-25
G · Actual harm
2024-04-09
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 2024-04-25
E · Potential for more than minimal harm
2023-12-12
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 2024-01-12
G · Actual harm
2023-03-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-03-27
G · Actual harm
2023-03-03
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 2023-03-27
G · Actual harm
2023-03-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-27
G · Actual harm
2023-03-03
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-03-03
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 2023-03-27
E · Potential for more than minimal harm
2023-03-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-03
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 2023-04-11
D · Potential for more than minimal harm
2023-03-03
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 2023-03-27
D · Potential for more than minimal harm
2023-03-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-03
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-03
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 2023-04-11
D · Potential for more than minimal harm
2023-03-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-03
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 2023-03-27
D · Potential for more than minimal harm
2023-03-03
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-03-27
D · Potential for more than minimal harm
2023-03-03
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 2023-03-27
D · Potential for more than minimal harm
2023-03-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-27
Penalties and ownership
What sits behind the stars
Ownership
Mamary, James
5% Or Greater Direct Ownership Interest · Individual
Mamary, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Mamary, Joshua
5% Or Greater Direct Ownership Interest · Individual
Mamary, James
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
M I Nursing & Restorative Center
Lawrence, MA
4-star overall rating with 4-star inspections with $21,916 in total fines with 3 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Nevins Nursing & Rehabilitation Center
Methuen, MA
1-star overall rating with 2-star inspections with $17,966 in total fines with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Cedar View Rehabilitation And Healthcare Center
Methuen, MA
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
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