JACKSON CREEK SENIOR LIVING

A revisit survey was completed on 5/7/26 for all previous deficiencies cited on 2/17/26. The facility is in compliance with all deficiencies that were cited.

A change-of-ownership survey was completed on 2/17/26. No deficiencies were cited. A change-of-ownership occurred on 1/26/26.

A licensure complaint, prompted by #CO41490, was completed on 2/17/26. Deficiencies were cited.

Based on records review and interviews, the residence failed to retain for three years following an employee's separation from employment, including the reasons for the separation, for Former Staff #4 (FS#4), affecting 100 current residents. Findings Include:In an interview with the administrator at 9:35 a.m., she explained that nearly all files dated before 1/26/26 were not retained by the new corporate owner as agreed upon, adding, "I tried to save some stuff". On 2/17/26 at approximately 2:00 p.m., the personnel file for FS#4 was requested from the administrator and not received. On 2/17/26 at approximately 2:00 p.m., the administrator confirmed that FS#4 was employed with the residence a year ago. She stated that her personnel file was lost when the residence was purchased by the new corporate owner on 1/26/26.

Based on records review and interviews, the residence failed to implement a policy and procedure for an effective information management system that includes a method of integration of paper-based and electronic health records (EHR) that allowed effective continuity of care, including effective management for capturing, reporting, processing, storing, and retrieving care/service data and information, affecting 100 current residents. Findings Include:The residence's "Record Keeping" policy and procedure dated 7/2025 read in part: "This community will maintain a record of all assisted living services established for each of its residents. The community must maintain and preserve all resident records in original, microfilm, electronic, or other similar form, for a period of at least five years from date of resident's discharge. ... All records must be available for examination by responsible party of the state licensing agency."An interview on 2/17/26 with Staff #2 at 8:35 a.m. revealed that the new corporate owner of the residence had required the staff to stop using their electronic health record (EHR) system and switch to a paper-based system. Stating, "it is slowing down the entire process and causing issues with our care for residents". She added that the administration has communicated that a new EHR was supposed to be implemented soon, but kept "running into problems". In an interview with the administrator at 9:35 a.m., she explained that nearly all files dated before 1/26/26 were not retained by the new corporate owner as agreed upon, adding, "I tried to save some stuff". The health information records (HIRs) for Residents #1-8 were requested from the administrator on 2/17/26 at 10:48 a.m., and partial files were provided for each. The administrator stated that she agreed that, since the change in ownership, the residence had not been able to effectively implement the record-keeping policy to ensure effective continuity of care.

Based on records review and interviews, the residence failed to maintain complete former resident records for at least three years following the termination of the resident's stay for Former Resident #9 (FR#9), affecting 100 current residents. Findings Include:The residence's "Record Keeping" policy and procedure dated 7/2025 read in part: "This community will maintain a record of all assisted living services established for each of its residents. The community must maintain and preserve all resident records in original, microfilm, electronic, or other similar form, for a period of at least five years from date of resident's discharge. ... All records must be available for examination by responsile party of the state licensing agency."In an interview with the administrator at 9:35 a.m., she explained that nearly all files dated before 1/26/26 were not retained by the new corporate owner as agreed upon, adding, "I tried to save some stuff". The health information record (HIR) for FR#9 was requested from the administrator on 2/17/26 at approximately 2:00 p.m. and was not received. In an interview with the administrator at approximately 2:00 p.m., she confirmed that FR#9 resided at the residence a year ago. She stated that her HIR was lost when the residence was purchased by the new corporate owner on 1/26/26.

A complaint revisit was completed on 5/8/25 for all previous deficiencies/the previous deficiency cited on 12/23/24. The residence is in compliance with all regulations surveyed.

An involuntary discharge appeal survey, prompted by #CO39329, was completed on 3/25/25. No deficiencies were cited.

A licensure complaint, prompted by #CO35683, #CO35684, #CO36563 and #CO38759 was completed on 12/23/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to ensure the administrator complied with all applicable state regulations to help prevent the possible development and transmission of Norovirus/Gastroenteritis and Coronavirus (COVID-19). Additionally, the residence failed to follow recommended contingency staffing protocols for their local health department (LHD), affecting 108 current residents. (Cross-reference S1130)Specifically, the residence failed to follow the LHD guidelines for reporting norovirus/gastroenteritis and collect specimens from different ill individuals. Specifically, the residence did not implement its communicable disease and infection prevention policy. The residence organized a line list of 21 residents and 13 staff members who experienced symptoms of vomiting and diarrhea (gastroenteritis). This failure created an immediate jeopardy risk to all 108 current residents. On 12/20/24, the department directed the residence to provide written evidence that the risk had been removed. Specifically, the residence failed to ensure the administrator managed day-to-day operations or adequate supervision of personnel during an outbreak of COVID-19. Furthermore, the residence failed to follow the local health department (LHD) guidelines for contingency staffing. Staff #5 was required to return to work on 12/6/24 after testing positive for COVID-19 on 12/5/24. Staff #5 was not required to continue isolation upon returning to work and actively worked with residents in the secure environment. Additionally, Staff #3 tested positive for COVID-19 on 12/4/24 and worked without taking the required five day isolation period. Residence supervision were aware of the positive COVID-19 tests; however, they failed to enforce contingency staffing protocols and staff continued to work after testing positive for COVID-19. This failure created an immediate jeopardy risk to all 108 current residents. On 12/20/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. GastroenteritisA . References and Residence PolicyChapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management, and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator," as that term is used in Title 25, Article 27, Part 1. The department's undated Summary of Guidelines for Investigation and Management of Norovirus Outbreaks in Healthcare and Residential Facilities read in part that in the event of an outbreak, the following steps should be taken:Notify the department or the local public health agency within four hours. Collect three to five stool specimens from different ill individuals and submit them to a commercial laboratory or to the department for norovirus testing and bacterial culture (on a fee for service basis). Try to collect specimens during the first 48 hours of illness while stool is still liquid. Outbreak control measures should not be delayed while waiting for test results. The residence's infection control policy, dated 8/10/23, read in part: "The residence will provide a safe, sanitary, and comfortable environment. The residence .... will help prevent the development and transmission of communicable diseases and infections. The elements of the infection prevention program consist of reporting the information to appropriate public health authorities and preventing the spread to other residents."B. ObservationsOn 12/20/24 at 7:55 a.m., Resident #2 vomited on her bed and the floor. The vomit was dark red and brown with a lumpy texture. On 12/20/24 at approximately 5:30 p.m., Resident #14 was observed in the dining room, trembling, with a runny nose, and was actively vomiting. Staff #3 took his body temperature; it measured 100.8 degrees Fahrenheit. C. InterviewsOn 12/20/24 at approximately 7:20 a.m., Confidential Staff #10 stated that a vomiting and diarrhea outbreak started on 12/13/24. Staff and residents in the assisted living and the secure environment experienced vomiting and diarrhea. Confidential Staff #10 stated that Resident #1 and two other residents had vomiting and diarrhea in the week prior to the onsite investigation. The confidential staff stated that Resident #1 had a change in baseline: Resident #1 was usually talkative and active but had not been so since becoming sick. On 12/20/24 at approximately 7:55 a.m., Resident #2 stated that she was not feeling well. She stated that she vomited on herself and the bed, and she felt nauseated. On 12/20/24 at approximately 8:15 a.m., Staff #8 stated that Resident #2 vomited, had diarrhea, and was nauseated while toileting. Staff #8 stated that Resident #1 vomited "violently." Staff #5 stated that residents who contracted gastroenteritis had sudden diarrhea and vomited without warning in the common areas such as dining rooms and hallways. On 12/20/24 at approximately 9:30 a.m., Confidential Staff #10 stated that a staff member sent an electronic text message to a group of staff members that read that she was sick with gastroenteritis symptoms. The confidential staff stated to an unknown agency staff that the administrator nor the regional nurse (RN) gave directions to help prevent the development and transmission of gastroenteritis except to wash hands and watch out for signs amongst residents. On 12/20/24 at approximately 4:00 p.m., Confidential Staff #9 and and an unknown agency staff stated that the administrator nor the RN gave direction to help prevent the development and transmission of gastroenteritis except to wash hands and watch out for the signs amongst residents. On 12/20/24 at approximately 11:30 a.m., the LHD representative stated that the residence had not reported any gastroenteritis-related outbreaks to thier department. She added that she expected the residence to have reported immediately once they started investigating the vomiting and diarrhea symptoms. On 12/20/24, at approximately 12:00 p.m., the RN stated that the residence had created a line list on 12/15/24 due to an outbreak of vomiting and diarrhea amongst residents and staff. On 12/20/24, at approximately 12:00 p.m., the administrator confirmed the start date of the line list. She stated that both residents and staff had gastroenteritis symptoms. On 12/20/24 at approximately 12:30 p.m., the administrator and the RN stated that they were not aware that Resident #2 had vomited on her bed with dark red and brown in color with lumpy textures (approximately four hours from the time of Resident #2's emesis). On 12/2/24 at 12:40 p.m., The RN and the administrator acknowledged the residence had a gastroenteritis outbreak. They affirmed that they did not collect stool specimens from different ill individuals, and subsequently the residence did not notify the LHD. The RN stated that she did not collect stool specimens because only primary care providers were able to request stool specimens. D. Record ReviewOn 12/20/24 at approximately 9:30 a.m., Confidential Staff #10's electronic text message revealed a staff member had called off work due to symptoms of gastroenteritis. Additional messages read in part to be aware that six residents with whom she had worked had symptoms also. On 12/20/24, at approximately 1:00 p.m., the RN provided a line list, titled "Outbreak Surveillance Form for Residents and Staff Members," that revealed the residence had counted 21 total residents and 13 staff members with gastroenteritis who had onset dates ranging from 12/12/24 through 12/20/24. The data in the document included the names, ages and sex of residents and staff, onset dates, symptoms, room numbers and illness duration. The columns for stool collection were labeled "no" and test results were labeled "not applicable." The line list revealed residents had gastroenteritis onset dates as follows:Resident #13 had an onset date of 12/16/24. Resident #1 had an onset date of 12/19/24. Residents #3 and #4 had an onset date of 12/20/24.2. COVID-19A. Residence PolicyThe residence COVID-19 policy, dated 9/2/2020, read in part that staff who exhibited symptoms of COVID-19 would be tested and excluded from work following Center for Disease Control (CDC) guidelines and would report any positive viral tests for COVID-19 to residence supervision staff. B. Record ReviewThe Residence Staff COVID-19 Line List read that Staff #3 tested positive for COVID-19 on 12/4/24 and that Staff #5 tested positive for COVID-19 on 12/5/24. The residence December 2024 staff schedule read that Staff #3 worked on 12/4/24 and 12/5/24, and that Staff #5 worked on 12/6/24. C. InterviewsDuring the onsite investigation, Confidential Staff #10 stated that Staff #5 was required to return to work on 12/6/24. Confidential Staff #10 stated that the RCC told Staff #5 that the LHD regulations did not require isolation anymore. During the onsite investigation, Confidential Staff #9 stated that Staff #3 took a COVID-19 test at the residence on 12/4/24 and had a positive test result. Confidential Staff #9 stated that management did not require Staff #3 to go home after testing positive, and the staff worked throughout the week. On 12/20/24 at approximately 2:30 p.m., an LHD representative stated that the LHD guidance for contingency staffing was that for those who tested positive for COVID-19 they needed to isolate at home for at least five days from the onset of the illness or beginning from the date of the positive test result if asymptomatic. The representative stated that staff should be free of fever for at least 24 hours with symptom improvement before returning to work. 3. The investigation established that the findings above placed the 108 current residents at immediate jeopardy risk for exposure to gastroenteritis. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/20/24 at 1:44 p.m., the RN submitted written evidence that read in pertinent part: The RN contacted the department on 12/20/24 for directives. The department's epidemiologist provided education to the administrator and the RN regarding COVID-19 and staffing protocols. The residence communicated with the department on 12/20/24 at 12:15 p.m. The administrator informed the department of the current residents who exhibited gastrointestinal (GI) symptoms and received direction for ongoing mitigation of the outbreak. The residence would follow the department guidelines for reportable outbreaks and would communicate any changes or challenges to the department. However, the written evidence did not indicate the risk had been removed because it did not address how the residence planned to ensure staff who tested positive for COVID-19 completed isolation during a COVID-19 outbreak. The RN was directed to submit additional written evidence. On 12/20/24 at 2:45 p.m., the RN submitted additional written evidence that read in pertinent part: Contingency staffing protocols will be determined by current regulations and recommendations. The residence will follow contingency staffing regulations. Staff will be excused from work after testing positive for COVID19. Non-positive staff and contracted staff will be asked to work additional shifts to fill positions of staff who tested positive. If staff shortages continued, residence changes from contingency staffing to crisis staffing would be considered. Staff who returned to work will be required to wear N-95 masks, social distance from other staff members and residents, and limit time spent with residents. This would be designated to residents as well ... Recommendations from the department are as follows; isolate ill individuals until 24 hours after resolution of symptoms, exclude sick staff from work, increased hand hygiene and environmental cleaning. The residence will follow these recommendations and any other department directions. However, the written evidence did not indicate that the risk had been removed because it did not include how the residence would monitor staff when ill and who would be responsible for monitoring and tracking those staff. The RN was directed to submit additional written evidence. On 12/20/24 at 4:37 p.m., the RN submitted additional written evidence that read in pertinent part: "This will be tracked on the outbreak line listing by the (administrator). Staff will be monitored by the director if ill and working and will track this on the outbreak line listing. This will include PPE (personal protective equipment) used while in (the residence), when they start symptoms, test positive, return to work and any changes of symptoms. During (an) outbreak of staff illness the (administrator)/designee will audit/observe proper PPE is used. Outbreak guidance will be reviewed by (the administrator) and regional team. Outbreak(s) will be reported within (four) hours to the appropriate agency."

Based on record review, and interview, the residence failed to determine appropriate routine staffing levels, and thus failed to meet requirements outlined in the resident care plan, affecting three of 108 current residents (#6, #9, #14). Findings include:1. Resident #14 was admitted to the residence on 1/14/24 with a diagnosis of dementia. A level of care evaluation, dated 1/14/24 read in part that Resident #14 did not resist care and that staff would provide maximum assistance daily with dressing, grooming, and toileting. 2. InterviewsOn 12/20/24 at approximately 5:00 p.m. Confidential Staff #9 stated that due to not having appropriate staffing levels, there were frequent times during the night and morning shifts when care needs would be missed or put off until late morning. She stated that several times in the afternoon she started her shift and noticed residents had not had assistance with toileting and that she attributed this to inappropriate staffing levels. On 12/23/24 at 11:34 a.m., a family member of Resident #14 stated that Resident #14 frequently smelled like urine. The family member stated that she believed the reason was due to inappropriate staffing levels to assist him with toileting as often as he needed. The family member also stated that she wanted to see more staff because she had see staff ask Resident #14 if he was hungry, and when he did not respond, staff moved on to a different task and then did not come back to follow up about eating, which resulted in and Resident #14 not eating. 3. ObservationDuring the onsite visit on 12/20/24 and 12/23/24 during breakfast in the secured environment, no staff were observed in the dining room between approximately 8:00 a.m. to 8:30 a.m. while residents were seated to eat breakfast. Residents were waiting for food to be served or were eating without being monitored. 4. Similar deficient practice was found for Residents #6 and #9.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of six sample residents (#11 and #12). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 8/10/23, read in part: "The administration of medication shall be documented at the time of administration."2. Record ReviewResident #12 was admitted to the residence on 12/17/19. A written practitioner's order, dated 10/23/24, directed the residence to administer Cymbalta 30 mg daily. However, the November 2024 medication administration record (MAR) contained a blank space on 11/2/24. Additional deficient practice was found for Resident #12's ammonium lactate solution, meloxicam and acetaminophen. 3. InterviewOn 12/20/24 at 3:42 p.m., the registered nurse (RN) and the administrator stated they expected staff to document medication administration at the time of administration and for there to be no blank spaces in the MARs. The RN acknowledged that she did not know why the QMAP did not document medication administration on 11/2/24 at the time of medication administration for Resident #12.4. Evidence revealed similar deficient practice for Resident #11.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.5 The assisted living residence shall have a policy and procedure regarding when a practitioner's assessment of a resident is appropriate. At a minimum, the assisted living residence shall contact the resident's primary practitioner when any of the following circumstances occur and follow the practitioner's recommendation regarding further action.(D) The resident has known exposure to a communicable disease.

A revisit survey was completed on 3/26/24 for all previous deficiencies cited on 1/4/24. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey with complaint #CO28264, #CO28805, #CO30927, #CO32211, #CO34376 was completed on 1/4/24. Deficiencies were cited.

Based on record review and interview the residence failed to ensure personnel file included written documentation of orientation and training for three of three sample staff (#1-#3), affecting 95 current residents. Findings include:On 1/4/23 at 9:30 a.m., the personnel files for Staff #1, Staff #2, and Staff #3 were requested from the administrator. Review of the personnel files for Staff #1-#3 revealed no written documentation of completion of orientation and training. On 1/4/23 at 3:08 p.m., the regional nurse stated she was aware of the requirement to have documentation of completion of orientation and training for personnel in their personnel files. She mentioned this had been an ongoing problem with their business office director not having the files organized and the residence did not conduct orientation and training for all staff.

Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of 15 sample residents (#6). Findings include:1. Residence policyThe residence's Medication Management policy, dated 8/10/23, read in part, the residence would administer medications as ordered by a practitioner. 2. Resident #6 was admitted on 3/12/22 with diagnoses including overactive bladder, actinic keratosis, spinal stenosis, complete traumatic amputation at knee level, arthritis, and malignant neoplasm of the prostate. A written practitioner's order, dated 12/12/23, directed the residence to administer clotrimazole cream 1% to the groin area twice daily. However, the December 2023 electronic medication administration record (eMAR) for Resident #6 read the medication start date of 12/20/23. A progress note from an outside source, dated 12/11/23, read in part Resident # 6 had an infection and required medication to be applied for 14 days. On 1/4/24 at approximately 9:30 a.m., an outside source stated that he provided care regularly for Resident #6. He stated that Resident #6 required a cream ordered by his practitioner in December 2023 that was not administered until a few weeks after it was ordered. He stated that Resident #6 complained about being uncomfortable, and he had observed that the rash spread and became very red. He stated that despite several attempts to help Resident #6 contact the wellness director (WD), he was unable to get a hold of her. On 1/4/23 at approximately 1:30 p.m., Resident #6 stated that he had an order from his practitioner that the residence failed to administer until approximately two weeks later. He stated that not having the medication caused increased itching. He stated he had been very uncomfortable. Resident #6 stated that he had tried several times to contact the WD by email and telephone. He stated that the staff informed him that his medication was sent to the wrong pharmacy. Staff also told him that the medication had arrived at the residence, but the WD failed to put the medication on the eMAR to be administered. On 1/4/23 at approximately 3:08 p.m., the regional nurse coordinator (RNC) stated that the practitioner's orders were expected to have been input into the eMAR no later than 24 hours after receiving the practitioner's order. She stated that she would have expected the WD to have input the medication by 12/13/23. On 1/4/23 at approximately 3:09 p.m., the WD stated that Resident #6 was not administered the medication as ordered because the facility had a problem getting the medication in stock. Additionally, she stated Resident #6 had refused the medication. She also stated that she had heard that he wanted the medication.

Based on observation, interview and record review, the residence failed to ensure a qualified medication administration person(QMAP) applied nationally recognized protocols for basic infection control when preparing and administering medications, affecting five of fifteen sample residents (#4, #5, #12, #13, #15 ). Findings Include:1. Reference and Residence Policya. According to the Centers for Disease Control and Prevention, Introduction to Hand Hygiene (2021), health care providers should wash their hands before touching a patient, after touching a patient or the patient's immediate environment, and immediately after glove removal. Centers for Disease Control and Prevention (1/8/21), Healthcare Providers and Introduction to Hand Hygiene, retrieved from: https://www.cdc.gov/handhygiene/providers/index.htmlb. The residence Infection Control policy, dated 8/10/23, read in part, "The staff must be aware of and use infection control precautions and isolation techniques to prevent the spread of infection."2. ObservationDuring medication administration on 1/4/24 from 7:45 a.m. to approximately 8:15 a.m., the following was observed:Staff #1 wiped down the medication cart and washed her hands. However, before she administered medications for Resident #13, Staff #1 touched the keys, computer, mouse, her hair and inside the medication cup. She then administered medications to Resident #13. Without washing or sanitizing her hands, Staff #1 repeated the same process while she prepared and administered medications for Resident #15. Without washing or sanitizing her hands, Staff #1 prepared medication for Resident #12. Staff #1 entered Resident #12 ' s room and touched Resident #12 ' s hand and blankets. Resident #12 dropped two pills and Staff #1 picked up the medication with her bare hands and handed them to Resident #12. Without washing or sanitizing her hands, Staff #1 repeated the same process while she prepared and administered medications for Resident #4. Without washing or sanitizing her hands, Staff #1 repeated the same process while she prepared and administered medications for Resident #4.3. InterviewOn 1/4/24 at 3:08 p.m., the nurse coordinator stated proper infection control practices for a QMAP would be washing or sanitizing hands between each pass. She stated if a medication was dropped by a resident, the expectation would be for the QMAP to destroy the medication and provide another dose for the resident.

Based on observation, record review, and interview, the residence failed to ensure the medication administration record (MAR) documented accurate information, including the date and time of administration, refusals, and resident responses to medications; all prescribed "as needed" (PRN) medications; the resident's room location; the date the order was received, affecting five of fifteen sample residents (#1, #6, #11, #12, #14). Findings include:1. Residence PolicyThe residence ' s Medication Management policy, dated 8/10/23, read in part, Procedure: Audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Further, the administrator and the Wellness Director or QMAP (qualified medication administration personnel) Supervisor will audit the accuracy and completeness of the medication administration records, medication error reports, and medication disposal records at least quarterly. Irregularities shall be investigated and resolved. 2. Resident #6 was admitted on 3/12/22 with diagnoses including overactive bladder, actinic keratosis, spinal stenosis, complete traumatic amputation at knee level, arthritis, and malignant neoplasm of the prostate. A written practitioner's order, dated 6/7/23, directed the residence to administer Hydrocodone-acetaminophen 5-325 mg, three tablets per day, as ordered. However, the November and December 2023 electronic medication administration record (eMAR) for Resident #6 had a blank on 11/21/23 and 12/20/23 for a total of two inaccurately documented doses. On 1/4/24 at 3:08 p.m., the regional nurse coordinator (RNC) stated that "Blanks" or "Holes" on the (eMAR) meant that medication was not given. She stated that she expected the staff to document the eMAR accurately, meaning staff should have marked the eMAR as the medication was not administered due to medication not available or the medication had been refused. 3. Record review and interview revealed similar deficient practice for Resident #1, admitted on 10/2/22.4. Record review and interview revealed similar deficient practice for Resident #11, admitted on 8/1/21.5. Record review and interview revealed similar deficient practice for Resident #12, admitted on 11/21/22.6. Record review and interview revealed similar deficient practice for Resident #14, admitted on 6/19/19.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.27 No stock medications shall be stored or administered by qualified medication administration persons. (A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name.

A revisit survey was completed on 6/29/23 for all previous deficiencies cited on 11/5/21. No deficiencies were cited.