Survey Date: Tuesday, August 26, 2014
Survey Type: Health
Deficiency: F0164 (Keep residents' personal and medical records private and confidential.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, September 28, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Monday, May 5, 2014
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, June 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Monday, May 5, 2014
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, June 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 16, 2014
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 16, 2014
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 16, 2014
Survey Type: Fire Safety
Deficiency: K0076 (Proper medical gas storage and administration areas.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 16, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0492 (Operate and provide services according to Federal, State, and local laws and professional standards.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0502 (Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0505 (Quickly tell the resident's doctor the results of laboratory tests.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Thursday, April 10, 2014
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, May 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, April 9, 2013
Survey Type: Health
Deficiency: F0333 (Ensure that residents are safe from serious medication errors.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, May 3, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, April 3, 2013
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, April 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0155 (Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directive)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0258 (Maintain comfortable sound levels.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0327 (Give each resident enough fluids to keep them healthy and prevent dehydration.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0387 (Make sure that doctors visit residents regularly, as required.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, March 27, 2013
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, October 18, 2012
Survey Type: Health
Deficiency: F0327 (Give each resident enough fluids to keep them healthy and prevent dehydration.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, December 12, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, February 14, 2012
Survey Type: Fire Safety
Deficiency: K0074 (Restrictions on the use of flammable curtains.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, March 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0154 (Ensure that residents are fully informed and understand their health status, care and treatments.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0368 (1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a sn)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Monday, February 13, 2012
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)