Inspection Reports for Harborview Health Systems Jesup
1090 W ORANGE ST, JESUP, GA, 31545
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 7, 2025, found that all previously cited deficiencies had been corrected. Prior inspections around that time showed no state health deficiencies and substantial compliance with Medicare/Medicaid regulations, though a Life Safety Code survey on April 9, 2025, noted two deficiencies related to fire alarm pull station mounting height and dust on sprinkler heads. Earlier reports from 2023 and before included deficiencies mainly involving medication administration errors and multiple life safety code issues such as emergency lighting, fire extinguisher maintenance, and storage near sprinkler heads. Complaint investigations over the years were consistently unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The overall trend indicates improvement in compliance, especially with recent follow-up surveys confirming correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
87 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 7, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
A State Licensure survey was conducted at Harborview Health Systems Jesup from April 8, 2025, through April 10, 2025.
Findings
The survey revealed there were no State Health deficiencies cited.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
A standard survey was conducted from 4/8/2025 through 4/10/2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00248781, GA00244684, GA00250800, GA00245176, and GA00250554 were investigated in conjunction with the standard survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 86
Capacity: 90
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to deficiencies including improper mounting height of a fire alarm pull station in the front lobby and sprinkler heads outside the dietary office being dusty, which could affect residents and staff safety.
Deficiencies (2)
Fire alarm pull station in the front lobby was mounted above 48 inches from floor level, not meeting proper mounting height requirements.
Two sprinkler heads outside the dietary office in the hallway had dust loading, failing to ensure sprinkler heads were free from dust.
Report Facts
Census: 86
Total Capacity: 90
Inspection Date: Apr 9, 2025
Fire alarm pull station mounting height: 48
Number of sprinkler heads with dust: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire alarm pull station mounting height and sprinkler head dust during facility tour |
Inspection Report
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 88
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the 4/27/2023 Recertification Survey.
Findings
All deficiencies cited as a result of the 4/27/2023 Recertification Survey were found to be corrected.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags were found to have been corrected during the Life Safety Code revisit.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
The inspection was a State Licensure survey conducted from April 24, 2023 through April 27, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to maintain a medication error rate of less than 5%, with 2 errors in 27 opportunities (7.40% error rate) affecting one resident during medication administration. Deficiencies involved incorrect dosage and improper crushing of medication against physician orders.
Deficiencies (1)
Failed to maintain a medication error rate of less than 5%, with 2 errors in 27 opportunities resulting in a 7.40% medication error rate.
Report Facts
Medication error rate: 7.4
Medication errors: 2
Residents observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered incorrect medication dosage and crushed medication against orders |
| Director of Nursing | Director of Nursing (DON) | Provided expectations regarding medication administration and error reporting |
| Assistant Administrator | Assistant Administrator | Interviewed regarding medication administration expectations |
Inspection Report
Routine
Census: 89
Deficiencies: 1
Date: Apr 27, 2023
Visit Reason
A standard survey was conducted at Harborview Health Systems Jesup from April 25, 2023 through April 27, 2023 by CertiSurv, LLC on behalf of the Department of Community Health (DCH) to assess compliance with Medicare/Medicaid regulations.
Findings
The facility failed to maintain a medication error rate of less than 5%, with 2 errors in 27 opportunities (7.40% error rate) affecting one resident during medication administration. Errors included administering an incorrect dose of docusate sodium and crushing an extended-release potassium chloride medication against policy.
Deficiencies (1)
Failed to maintain a medication error rate of less than 5%, with 2 errors in 27 opportunities affecting Resident #79.
Report Facts
Medication error rate: 7.4
Resident census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered incorrect medication dose and crushed medication against policy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration expectations and errors |
| Assistant Administrator | Assistant Administrator | Interviewed regarding medication administration expectations |
Inspection Report
Life Safety
Census: 89
Capacity: 90
Deficiencies: 10
Date: Apr 27, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including emergency lighting failures, sprinkler system maintenance issues, improper storage near sprinkler heads, failure to remove items from sprinkler piping, expired fire extinguisher, improperly sealed smoke/firewalls, smoke/fire doors not closing properly, improperly installed power strip, open panel boxes, prohibited portable space heaters without documentation, and use of a 6-way receptacle in the housekeeping office.
Deficiencies (10)
Emergency lights in the kitchen and maintenance office failed to operate when tested.
Failed to ensure storage is below 18 inches near sprinkler heads in medical records room and lien closets.
Failed to ensure items are removed from sprinkler piping; wires supported by sprinkler piping above lunchroom smoke doors.
Failed to check class K fire extinguisher; extinguisher expired (last serviced January 2022) in kitchen.
Failed to properly seal smoke/firewall; raised wall penetrations and holes not sealed in 200 hall and above lunchroom smoke doors.
Failed to ensure smoke/fire doors close properly; lunchroom smoke/fire doors failed to close properly when tested.
Failed to ensure power strip was properly installed; power strip was on the floor in DON office.
Failed to close open spaces in laundry room and 300 hall panel boxes; panel boxes had open spaces.
Failed to provide documentation that portable space heater's heating element does not exceed 212 degrees Fahrenheit in DON office.
Failed to remove 6-way receptacle plug in housekeeping office.
Report Facts
Census: 89
Total Capacity: 90
Inspection Date: Apr 27, 2023
Fire Extinguisher Last Service Date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00229833.
Complaint Details
Complaint #GA00229833 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 18, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00227652, #GA00223101, and #GA00222710.
Complaint Details
Complaints #GA00227652, #GA00223101, and #GA00222710 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 18, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00219616.
Complaint Details
Complaint #GA00219616 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00216734, #GA00216902, #GA00217225, and #GA00217494.
Complaint Details
Complaints #GA00216734, #GA00216902, #GA00217225, and #GA00217494 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Harborview Health Systems Jesup, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Jul 23, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/27/21 Recertification Survey.
Findings
All deficiencies cited in the previous Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 19, 2021
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Renewal
Census: 86
Deficiencies: 3
Date: May 27, 2021
Visit Reason
A licensure survey was conducted from May 24, 2021 through May 27, 2021 to assess the facility's compliance with regulatory requirements.
Findings
The facility was found not in substantial compliance due to failures in infection control practices, including improper use of PPE by staff and visitors, failure to remind residents to wear masks outside their rooms, and failure to keep an indwelling catheter bag off the floor for a sampled resident.
Deficiencies (3)
Failure to follow transmission-based precautions related to wearing appropriate PPE for residents on isolation precautions and failure to doff PPE when exiting rooms.
Failure to remind residents to wear masks when out of their rooms.
Failure to ensure the indwelling catheter bag was not touching the floor for one sampled resident (R33).
Report Facts
Census: 86
Dates of survey: Survey conducted from May 24, 2021 through May 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in findings for failing to wear full PPE when passing medication in isolation rooms |
| CNA4 | Certified Nurse Aide | Named in findings for failing to doff PPE when exiting isolation room |
| Medical Director | Observed failing to don and doff proper PPE in quarantine room | |
| Director of Nursing | Director of Nursing (DON) | Confirmed PPE policy and deficiencies |
| LPN2 | Licensed Practical Nurse | Interviewed regarding PPE and mask use for residents |
| LPN3 | Licensed Practical Nurse | Interviewed regarding resident mask use during transport |
| LPN4 | Licensed Practical Nurse | Observed urinary catheter bag on floor and noted infection control concern |
| Infection Preventionist | Infection Preventionist (IP) | Provided information on PPE policies and infection control |
Inspection Report
Routine
Census: 86
Deficiencies: 4
Date: May 27, 2021
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident dignity related to catheter bag coverage, Medicaid/Medicare coverage notices, accuracy of assessments, infection prevention and control practices including PPE use and catheter bag handling.
Deficiencies (4)
Failure to maintain dignity by not covering a resident's indwelling urinary catheter collection bag, which was visible from the doorway and when in wheelchair.
Failure to issue accurate Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN) including appeal rights for two residents.
Inaccurate coding of Minimum Data Set (MDS) assessment related to a resident's weight loss program without physician order.
Failure to follow infection prevention and control program requirements including improper PPE use by staff and medical director, failure to doff PPE properly, failure to remind residents to wear masks, and catheter bag touching floor.
Report Facts
Resident census: 86
Residents sampled: 19
Residents with inaccurate SNF ABN: 2
Residents with catheter bag dignity issue: 1
Residents with infection control issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated no bag covering urinary collection bag was a dignity concern for resident R33 |
| Certified Nurse Aide 1 | Certified Nurse Aide | Confirmed urinary catheter bag was visible and uncovered for resident R33 |
| Business Office Manager | Business Office Manager | Responsible for completing SNF ABN and acknowledged forms lacked appeal information |
| Medical Director | Medical Director | Observed not donning proper PPE in quarantine room and acknowledged error |
| Director of Nursing | Director of Nursing | Confirmed Medical Director should have followed PPE policy |
| Infection Preventionist | Infection Preventionist | Provided information on PPE requirements and infection control policies |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Observed not wearing full PPE when entering isolation rooms |
| Certified Nurse Aide 4 | Certified Nurse Aide | Forgot to doff PPE when exiting isolation room |
| MDS Coordinator | MDS Coordinator | Coded resident as on weight loss regimen incorrectly |
Inspection Report
Life Safety
Census: 85
Capacity: 90
Deficiencies: 9
Date: May 24, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed exit corridors, improperly sealed fire-rated doors, fire alarm system issues, sprinkler system maintenance deficiencies, unsealed penetrations in smoke walls, uncovered junction boxes, improper use of extension cords, and improper storage and securing of oxygen cylinders.
Deficiencies (9)
Failed to keep exit corridors clear of obstructions affecting 3 smoke compartments.
Failed to ensure fire rated doors and compartments are sealed properly; storage room door had holes and salon door was removed affecting 3 smoke compartments.
Fire alarm breaker is not red, not properly secured, and not clearly identified.
Ceiling tiles missing in corridor outside salon causing heat to escape and sprinkler not to activate affecting 1 smoke compartment.
Failed to properly seal penetrations in fire/smoke walls with approved product affecting 3 smoke compartments.
Failed to properly cover junction boxes exposing wiring affecting boiler/utility room and 1 smoke compartment.
Improper use of extension cords as permanent wiring in laundry room and 1 smoke compartment.
Failed to store oxygen cylinders properly; storage not labeled properly.
Failed to secure oxygen cylinders properly.
Report Facts
Census: 85
Total Capacity: 90
Smoke Compartments Affected: 3
Smoke Compartments Affected: 1
Smoke Compartments Affected: 3
Smoke Compartments Affected: 1
Smoke Compartments Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 05/24/2021 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00212829.
Complaint Details
Complaint #GA00212829 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint was unsubstantiated and no regulatory violations were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a COVID-19 Focused Infection Control Survey to investigate complaint #GA00207366.
Complaint Details
Complaint #GA00207366 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with infection control regulations and COVID-19 preparedness guidelines.
Inspection Report
Routine
Census: 72
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 72
Inspection Report
Routine
Census: 87
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related regulations and preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: Jul 29, 2019
Visit Reason
An abbreviated survey was conducted from July 26, 2019 through July 29, 2019 to investigate complaints GA00196125, GA00196262, GA00197909, and GA00197238.
Complaint Details
The visit was complaint-related, investigating four complaints identified by their complaint numbers. No deficiencies were cited indicating substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Resident census: 88
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 18, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00192177.
Complaint Details
Complaint GA00192177 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 28, 2018
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the standard survey of 8/23/18.
Findings
All deficiencies cited in the standard survey of 8/23/18 were found to be corrected during the revisit survey conducted on 9/27/18 through 9/28/18.
Inspection Report
Life Safety
Census: 85
Capacity: 90
Deficiencies: 8
Date: Aug 21, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition standards.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements, including deficiencies in emergency preparedness planning, emergency lighting testing, fire alarm system maintenance, and smoke barrier construction.
Deficiencies (8)
Emergency Preparedness Plan did not include a system to track on-duty staff and sheltered patients during an emergency.
Emergency Preparedness Plan lacked policies and procedures documenting the facility's role under a waiver declared by the Secretary.
Emergency Preparedness Plan did not contain a communication plan meeting federal, state, and local requirements.
Emergency Preparedness Plan did not include names and contact information for required parties in the communication plan.
Emergency Preparedness Plan lacked a documented facility-based and community-based risk assessment utilizing an all-hazards approach.
Emergency lighting was not tested at proper intervals and documentation was incomplete for the last 12 months.
Fire alarm system batteries were not stamped with the date of manufacture, indicating improper maintenance.
Smoke barriers were breached by unsealed holes and cables, failing to maintain a 1/2-hour fire resistance rating.
Report Facts
Residents at risk: 85
Certified beds: 90
Months of missing emergency lighting test documentation: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan deficiencies, emergency lighting testing, fire alarm maintenance, and smoke barrier issues. |
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 0
Date: Apr 3, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00186321 at Harborview Health Systems.
Complaint Details
Investigation of complaint GA00186321; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Facility census: 83
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2017
Visit Reason
A revisit was conducted on 9/18/17 for the recertification survey originally conducted on 8/17/17.
Findings
The revisit revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 9/8/17.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2017
Visit Reason
A complaint survey was initiated and conducted on September 14, 2017.
Complaint Details
The complaint survey (GA00179116) was unsubstantiated.
Findings
The complaint investigation was concluded as unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 87
Deficiencies: 3
Date: Aug 17, 2017
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including accurate issuance of Medicare Non-Coverage notices, assurance of financial security for resident funds, and inclusion of certified nursing assistants in care plan meetings.
Deficiencies (3)
Facility failed to provide accurate Notice of Medicare Non-Coverage and failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice for certain residents discharged from Medicare Part A services.
Facility failed to have a surety bond to cover the amount of funds in the resident trust account, with the resident trust account balance exceeding the bond amount on multiple occasions.
Facility failed to include certified nursing assistants (CNAs), a key member of the interdisciplinary team, in care plan meetings for three residents reviewed.
Report Facts
Resident census: 87
Residents with personal funds accounts: 61
Surety bond amount: 25347.02
Number of residents in sample: 23
Number of care plan meetings reviewed for R#31: 5
Number of care plan meetings reviewed for R#82: 3
Number of care plan meetings reviewed for R#88: 5
Inspection Report
Life Safety
Census: 87
Capacity: 90
Deficiencies: 0
Date: Aug 15, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and related NFPA standards during the survey.
Report Facts
Census: 87
Certified beds: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2017
Visit Reason
The inspection was conducted as a standard survey in conjunction with complaint GA00168988 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00168988 was investigated during the visit; no deficiencies were found.
Findings
No deficiencies were cited during the inspection.
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