| Deducted | Remarks |
| 1 | 5.3 Provide adequate lighting of a minimum 20 foot candles in halls and stairways.// Repair blown lights in the kitchen area. |
| 3 | 5.6 Provide adequate heating and ventilation to maintain an air temperature of a minimum of 68F and not to exceed 90F measured at a distance of 3 ft above the floor in all rooms at all times.// In rooms 7-17 ambient temp of 79F. |
| 2 | 6.1.1 Maintain all interior walls, ceiling and floors in good repair.// Repair various damaged floor tiles in the hallway.// Repair the ceiling in staff restroom. |
| 3 | 2.5.2 Complete and document an annual assessment of suitability and maintain a copy in the resident's file.//All resident assessments are not provided.
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| 3 | 2.9.1 Complete a Resident Agreement on the date of admission for each resident.// Update resident agreements yearly. |