Cycle 1
Health 2024-12-17 · Fire 2024-12-17
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Lincoln, NE
Tabitha Nursing Home
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
4720 Randolph Street, Lincoln, NE
(402) 483-7671
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
197
Certified beds
Average residents
131
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.84
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.82
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
5.62
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
5.04
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.86
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
554
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
67.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0211
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.68
Baseline 16.82% · Performance 18.34% · Measure score 6.68 · Achievement 6.68 · Improvement 0
Healthcare-associated infections
6.48
Baseline 5.85% · Performance 5.90% · Measure score 6.48 · Achievement 6.48 · Improvement 0
Total nurse turnover
4.42
Baseline 47.45% · Performance 45.59% · Measure score 4.42 · Achievement 4.42 · Improvement 0.32
Adjusted total nurse staffing
9.49
Baseline 5.29 hours · Performance 5.78 hours · Measure score 9.49 · Achievement 9.49 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 730 · Observed rate 7.95% · Lower 95% interval 7.61% |
| Discharge to community | 68.02% |
50.57%
17.4 pts better
|
Better than the National Rate · Eligible stays 645 · Observed rate 67.6% · Lower 95% interval 64.06% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 63.99% |
95.27%
31.3 pts worse
|
Numerator 295 · Denominator 461 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 6 · Denominator 461 |
| Discharge self-care score | 61.17% |
53.69%
7.5 pts better
|
Numerator 230 · Denominator 376 |
| Discharge mobility score | 47.07% |
50.94%
3.9 pts worse
|
Numerator 177 · Denominator 376 |
| Pressure ulcers or injuries, new or worsened | 3.47% |
2.29%
1.2 pts worse
|
Numerator 16 · Denominator 461 · Adjusted rate 3.79% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 487 · Observed rate 4.52% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 2.15% |
8.2%
6 pts worse
|
Numerator 13 · Denominator 606 |
| Staff flu vaccination coverage | 48.33% |
42%
6.3 pts better
|
Numerator 261 · Denominator 540 |
| Discharge function score | 62.23% |
56.45%
5.8 pts better
|
Numerator 234 · Denominator 376 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 305 · Denominator 305 |
| Transfer of health information to patient | 98.82% |
96.28%
2.5 pts better
|
Numerator 84 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 55 · Denominator 187 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
92.8%
5.4 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.0% · Q3 98.0% · Q4 96.8% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
96.1%
2 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 | 3.4% |
4.5%
1.1 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.0% · Q3 4.0% · Q4 6.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.4%
3.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.1% · Q4 1.2% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.3%
1.4 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.8% · Q3 3.8% · Q4 3.7% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
19.5%
4.9 pts worse
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 23.7% · Q3 26.6% · Q4 22.0% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
21.6%
2.7 pts better
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 14.8% · Q3 20.3% · Q4 18.0% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 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 | 33.5% |
20.4%
13.1 pts worse
|
16.3%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 58.6% · Q2 37.4% · Q3 23.5% · Q4 11.3% · 4Q avg 33.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
19.9%
2.1 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 29.7% · Q3 23.0% · Q4 9.3% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.6%
0.9 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
2.9%
3.7 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.4% · Q3 7.0% · Q4 6.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
26.6%
0.7 pts better
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 24.9% · Q3 23.8% · Q4 27.3% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.3%
0.3 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 4.4% · Q3 3.4% · Q4 0.9% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
80.5%
13.6 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 94.2% · Q3 95.0% · Q4 91.6% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
11.6%
1.6 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
2.4%
0.6 pts better
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.0% · Q3 2.3% · Q4 2.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
75.9%
12.2 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
20.9%
0.5 pts worse
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 17.9% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-02 · Fire 2023-02-02
8 health deficiencies
Top issue: Infection Control (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
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 2025-01-31
F · Potential for more than minimal harm
2024-12-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-17
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 2025-01-31
E · Potential for more than minimal harm
2024-12-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-17
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-16
F · Potential for more than minimal harm
2024-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-16
F · Potential for more than minimal harm
2024-01-09
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-09
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 2024-02-16
E · Potential for more than minimal harm
2024-01-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-16
F · Potential for more than minimal harm
2023-02-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
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 2023-03-19
F · Potential for more than minimal harm
2023-02-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-19
E · Potential for more than minimal harm
2023-02-02
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-03-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-11-18
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 2025-12-29
F · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-17
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 2025-01-31
D · Potential for more than minimal harm
2024-12-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-17
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 2025-01-31
D · Potential for more than minimal harm
2024-12-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-01-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-27
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 2023-10-20
F · Potential for more than minimal harm
2023-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-03-19
F · Potential for more than minimal harm
2023-02-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-19
D · Potential for more than minimal harm
2023-02-02
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 2023-03-19
D · Potential for more than minimal harm
2023-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-19
Penalties and ownership
What sits behind the stars
Ownership
Eventide Nebraska Senior Living LLC
5% Or Greater Indirect Ownership Interest · Organization
Bock, Jodee
Corporate Director · Individual
Brandt, Terry
Corporate Director · Individual
Bye, Robert
Corporate Director · Individual
Bye, Robert
Corporate Officer · Individual
Cerny, Sabrina
Contracted Managing Employee · Individual
Eventide
Operational/Managerial Control · Organization
Fischbach, Tyler
Corporate Director · Individual
Gulbranson, Patrick
Corporate Director · Individual
Halvorson, Joseph
Corporate Director · Individual
Hvidston, Luke
Corporate Director · Individual
Hvidston, Luke
Corporate Officer · Individual
Johnson, Vikki
Corporate Director · Individual
Johnson, Vikki
Corporate Officer · Individual
Larson-Casselton, Cindy
Corporate Director · Individual
Lee, Judith
Corporate Director · Individual
Lunak, Brandon
Corporate Director · Individual
Noack, Tonya
W-2 Managing Employee · Individual
Ohe, Darin
Operational/Managerial Control · Individual
Riewer, Jon
Corporate Officer · Individual
Schafer, Eric
Corporate Director · Individual
Seljevold, Peter
Corporate Director · Individual
Swenson, Karla
Corporate Director · Individual
Nearby options
Other facilities in reach
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Gateway Vista
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3-star overall rating with 3-star inspections with $8,659 in total fines with 4 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
St. Jane de Chantal
Lincoln, NE
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Ambassador Health of Lincoln
Lincoln, NE
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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