Wickliffe, OH

Wickliffe Country Place

3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

1919 Bishop Rd, Wickliffe, OH

(440) 944-9400

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

170

Certified beds

Average residents

110

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Health Services

Operator or chain grouping

Approved since

1978-07-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 3 overall / 3 health / 2 staffing / 5 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

0.71

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.05

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.18

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.94

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.76

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.30

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.68

CMS adjusted RN staffing hours

Adjusted total hours

3.79

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

85%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

68%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,342

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.05

Composite VBP score used to determine payment impact.

Payment multiplier

0.9844

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.17

Baseline 22.25% · Performance 20.33% · Measure score 3.17 · Achievement 2.38 · Improvement 3.17

Healthcare-associated infections

4.78

Baseline 6.21% · Performance 6.41% · Measure score 4.78 · Achievement 4.78 · Improvement 0

Total nurse turnover

2.87

Baseline 76.78% · Performance 59.29% · Measure score 2.87 · Achievement 1.07 · Improvement 2.87

Adjusted total nurse staffing

0

Baseline 3.14 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.77%
10.72%
About the same
No Different than the National Rate · Eligible stays 65 · Observed rate 13.85% · Lower 95% interval 7.08%
Discharge to community 48.96%
50.57%
1.6 pts worse
No Different than the National Rate · Eligible stays 69 · Observed rate 37.68% · Lower 95% interval 35.17%
Medicare spending per beneficiary 0.85
1.02
0.2 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 44 · Denominator 44
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 44
Discharge self-care score 66.67%
53.69%
13 pts better
Numerator 18 · Denominator 27
Discharge mobility score 48.15%
50.94%
2.8 pts worse
Numerator 13 · Denominator 27
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 6.41%
7.12%
0.7 pts better
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 3.75%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 171
Staff flu vaccination coverage 1.13%
42%
40.9 pts worse
Numerator 2 · Denominator 177
Discharge function score 70.37%
56.45%
13.9 pts better
Numerator 19 · Denominator 27
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 22 · Denominator 22
Resident COVID-19 vaccinations up to date 10.34%
25.2%
14.9 pts worse
Numerator 3 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.2%
92.4%
5.8 pts better
93.4%
4.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 96.1% · Q3 98.9% · Q4 100.0% · 4Q avg 98.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94.7%
94.5%
0.2 pts better
95.5%
0.8 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of long-stay residents experiencing one or more falls with major injury 2.3%
3.3%
1 pts better
3.3%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.9% · Q3 3.3% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 13.5%
26.1%
12.6 pts better
11.4%
2.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 9.7% · Q3 10.9% · Q4 12.3% · 4Q avg 13.5%
Percentage of long-stay residents who lose too much weight 11.2%
6.2%
5 pts worse
5.4%
5.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 13.8% · Q3 13.9% · Q4 10.7% · 4Q avg 11.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.4%
25.4%
12 pts better
19.6%
6.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 10.6% · Q3 12.7% · Q4 14.5% · 4Q avg 13.4%
Percentage of long-stay residents who received an antipsychotic medication 5.4%
11.5%
6.1 pts better
16.7%
11.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.7% · Q3 9.3% · Q4 3.5% · 4Q avg 5.4% · 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 6.2%
7.7%
1.5 pts better
16.3%
10.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.5% · Q3 11.7% · Q4 3.1% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 8.4%
6.2%
2.2 pts worse
14.9%
6.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.0% · Q3 6.8% · Q4 10.0% · 4Q avg 8.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.5%
0.2%
0.3 pts worse
1.0%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.5%
0.5%
About the same
1.7%
1.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 31.6%
21.7%
9.9 pts worse
19.8%
11.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 35.3% · Q3 35.0% · Q4 33.3% · 4Q avg 31.6%
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 5.3% · Q2 3.9% · Q3 1.8% · Q4 0.9% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 81.0%
78.1%
2.9 pts better
81.7%
0.7 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 78.2% · Q3 76.9% · Q4 83.0% · 4Q avg 81.0%
Percentage of short-stay residents who had an outpatient emergency department visit 3.5%
12.5%
9 pts better
12.0%
8.5 pts better
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 4.4% · Expected 14.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.6%
1.2%
0.6 pts better
1.6%
1 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 1.5% · 4Q avg 0.6% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 63.9%
75.6%
11.7 pts worse
79.7%
15.8 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 25.2%
25.1%
0.1 pts worse
23.9%
1.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 35.6% · Expected 33.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-26 · Fire 2024-09-26

14 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

6 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2022-09-29 · Fire 2022-09-29

15 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

8 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 3 Health 2019-09-26 · Fire 2019-09-26

6 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-11

F · Potential for more than minimal harm 2024-09-26

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-10-11

F · Potential for more than minimal harm 2024-09-26

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-09-26

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 2024-10-11

E · Potential for more than minimal harm 2024-09-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-10-11

E · Potential for more than minimal harm 2024-09-26

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-10-11

F · Potential for more than minimal harm 2022-09-29

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 2022-10-25

F · Potential for more than minimal harm 2022-09-29

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-29

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-29

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-29

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-29

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-10-25

F · Potential for more than minimal harm 2019-09-26

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 2019-10-18

F · Potential for more than minimal harm 2019-09-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-10-18

E · Potential for more than minimal harm 2019-09-26

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-10-18

E · Potential for more than minimal harm 2019-09-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-10-18

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-17

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 2025-11-18

D · Potential for more than minimal harm 2025-11-17

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-11-18

D · Potential for more than minimal harm 2025-11-17

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-11-18

E · Potential for more than minimal harm 2025-01-30

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 2025-02-03

F · Potential for more than minimal harm 2024-09-26

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 2024-10-11

F · Potential for more than minimal harm 2024-09-26

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-09-26

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-10-11

D · Potential for more than minimal harm 2024-09-26

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 2024-10-11

D · Potential for more than minimal harm 2024-09-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-11

F · Potential for more than minimal harm 2024-03-28

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-04-08

D · Potential for more than minimal harm 2023-07-11

F660 · Resident Assessment and Care Planning Deficiencies

Health

Plan the resident's discharge to meet the resident's goals and needs.

Corrected 2023-07-20

D · Potential for more than minimal harm 2023-07-11

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 2023-07-20

G · Actual harm 2022-09-29

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-29

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 2022-10-25

F · Potential for more than minimal harm 2022-09-29

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-29

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 2022-10-25

E · Potential for more than minimal harm 2022-09-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-29

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 2022-10-25

D · Potential for more than minimal harm 2022-09-29

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 2022-10-25

D · Potential for more than minimal harm 2022-09-29

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 2022-10-25

D · Potential for more than minimal harm 2022-09-29

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 2022-10-25

D · Potential for more than minimal harm 2022-09-29

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 2022-10-25

D · Potential for more than minimal harm 2022-09-29

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-29

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-29

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2022-10-25

F · Potential for more than minimal harm 2019-09-26

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 2019-10-18

F · Potential for more than minimal harm 2019-09-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-10-18

E · Potential for more than minimal harm 2019-09-26

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 2019-10-18

D · Potential for more than minimal harm 2019-09-26

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2019-10-18

Penalties and ownership

What sits behind the stars

Ownership

Oh 10 Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 10 facilities 2022-07-06
Cc Oh10 Opco LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Chavos221 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Chavos221 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Lionsview Opco Nr LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Lionsview Sc LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Living26 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Living26 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Sapphire143 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Sapphire143 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

0% 10 facilities 2022-07-06
Sharvit, Eliav

Corporate Officer · Individual

0% 8 facilities 2007-06-22
Stump, Barry

Corporate Officer · Individual

0% 10 facilities 2007-06-22
Stump, Barry

W-2 Managing Employee · Individual

0% 10 facilities 2007-06-22

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2-star overall rating with 2-star inspections with $137,255 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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#3

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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

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Staffing
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