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When the Department of Health, Office of Health Care Facilities Licensure and Certification surveys a nursing facility and finds it is not in compliance with the regulation, it cites the deficient practice. Each health and Life Safe Code deficiency is assigned a Scope and Severity (SS=__), which can be found in the left-side column of the survey report, in the column marked (X4) ID Prefix Tag. For example, a deficiency noted as SS= L means the deficient practice is widespread in the facility and presents an immediate threat to the health or safety of residents. Conversely, a deficiency noted as SS=A, indicates the practice is isolated and has the potential for a minor negative impact on residents. Just above the SS=__ is the survey tag reference number.

Scope has three levels: isolated, pattern, and widespread:

Isolated — when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.

Isolated —

Pattern when more than a very limited number of residents are affected and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.


Widespread When the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents.


Severity has four levels: Level 1, Level 2, Level 3, and Level 4:


Level 1 has the potential for causing no more than a minor negative impact on the resident(s).

Level 1

Level 2 has the potential for no more than minimal physical, mental, and/or psychosocial discomfort to the resident and/or has the potential to compromise the resident(s) ability to maintain and/or reach his/her highest practicable physical, mental, and/or psychosocial well-being.

Level 2

Level 3 results in a negative outcome that has compromised the resident(s) ability to maintain and/or reach his/her highest practicable physical, mental, and psychosocial well-being.

Hi Amber, It is actually very important that you get your MMA and Hcy levels tested. From my reading, one of the reasons that they don’t routinely test it is because the tests are very expensive. Another reason is that most doctors do not really know much about deficiency and how it affects Hcy and MMA and what the consequences are. If you only get your B12 levels tested be aware that the US lower limit of normal is for clinical deficiency, such as you would expect if you were anemic. This level is way too low. There are many papers that show that Hcy and MMA start to increase when your levels drop below 300 pmol/Lm or 406 pg/ml. Elevated MMA leads to gradual demylination of your neurones, whilst elevated Hcy leads to lots of cardiovascular events, so it is quite important that you keep them low all the time.


Just following up to see if you have had any additional feedback about your lab tests and B12+ levels. I just tested my B12, MMA, Hcy and Folate levels and am waiting to see my practitioner to go over them. My B12 was >2000 and I have been doing injections (weekly until now, and twice weekly before that) for a couple of years, so we shall see. If I end up staying on B12 supplements I would sure like to use the sublingual ones going forward. I love the energy levels I’ve had since starting the injections but to be honest, I really do not like them. So we shall see, and I’ve love to hear more about your results if you feel like sharing.


Hi Felicia, I just picked up my results a couple days ago. I was quite surprised by them! The good news…for the first time ever my hematacrit (blood count), has gone up a little compared to what it was 4 months ago! This has never happened before…I’ve been anemic all my life, so I’m thrilled to finally see something helping with that. I knew I have less brain fog, and better days lately of being able to function, but it’s good to see it on paper. The weird stuff now….I’m really regretting not insisting I have the Hcy and MMA tests done, coz it could’ve clarified things: My B12 is 708 pg/ml, and my folic acid level is >24 ng/ml which is “Excessive”. To me, this really points to a problem with my processing folic acid into its active form, so it accumulates in the blood, unused. And not enough active folate, of course means the B12, which is used in the same metabolic pathway, is also not being utilized, hence my B12 deficiency symptoms. That’s my theory anyway….I’ve sent out a 23andMe test and am awaiting the results to see if I have the MTHFR gene defect (I strongly suspect I do). In the meantime I’m continuing Freddds protocol, but I tend to still get headaches very easily if I don’t take enough methylfolate…I might need a much higher dosage than what I’m currently taking. I’m looking around for a higher dose methylfolate, so far I found one but it’s very expensive. Do share your own results if you don’t mind, I’d be very interested.

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Review of Statue of Liberty
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Statue of Liberty and Ellis Island Ticket
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The Statue of Liberty Enlightening the World was a gift of friendship from the people of France to the people of the United States and is a universal symbol of freedom and democracy. The Statue of Liberty was dedicated on October 28, 1886, designated as a National Monument in 1924 and restored for her centennial on July 4, 1986.
Reviewed 27 November 2017
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Reviewed 27 November 2017

Wasn’t able to tickets to th crown but that didn’t matter, being at the base was good enough. Be prepared for wind, lots of wind. Park Rangers won’t allow anyone to take a backpack or large bag to the second level and after getting there I could see why. There is literally only room for one person to stand or walk on the base.In one direction the wind was so slow strong it kept people from being able to walk that direction.

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Bennett CL, Christie J, Ramsdell F, et al. The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is caused by mutations of FOXP3. . 2001 Jan. 27(1):20-1. .

Freeman AF, Davis J, Anderson VL, et al. Pneumocystis jiroveci infection in patients with hyper-immunoglobulin E syndrome. . 2006 Oct. 118(4):e1271-5. .

Grimbacher B, Holland SM, Puck JM. Hyper-IgE syndromes. . 2005 Feb. 203:244-50. .

Ling JC, Freeman AF, Gharib AM, et al. Coronary artery aneurysms in patients with hyper IgE recurrent infection syndrome. . 2007 Mar. 122(3):255-8. .

Van der Meer JW, Weemaes CM, van Krieken JH, et al. Critical aneurysmal dilataion of the thoracic aorta in young adolescents with variant hyperimmunoglobulin e syndrome. . 2006. 259:615-8. .

Media Gallery
Chest radiograph of a patient with autosomal dominant (AD) hyperimmunoglobulin E syndrome (HIES) and a lung abscess following multiple staphylococcal pneumonias. Aspergillus fumigatus was isolated from the abscess.
Father and daughter with autosomal dominant (AD) hyperimmunoglobulin E syndrome (HIES). Note the father's distinctive facies with prominent forehead, deep-set eyes, broad nasal bridge, and wide interalar distance.
Mother and son with autosomal dominant (AD) hyperimmunoglobulin E syndrome (HIES). Note the mother's distinctive facies. She had a history of multiple deep-seated abscesses that took months to heal after incision and drainage.
Contributor Information and Disclosures

Harumi Jyonouchi, MD Faculty, Division of Allergy/Immunology and Infectious Diseases, Department of Pediatrics, Saint Peter's University Hospital Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology , DRESSES Short dresses Lawrence Steele kUr65
, American Association of Immunologists , American Medical Association , Clinical Immunology Society , New York Academy of Sciences , Society for Experimental Biology and Medicine , Society for Pediatric Research , Society for Mucosal Immunology Disclosure: Nothing to disclose.

Harumi Jyonouchi, MD
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Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Nothing to disclose.

Mary L Windle, PharmD

David J Valacer, MD David J Valacer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology , American Academy of Pediatrics , American Association for the Advancement of Science , American Thoracic Society , New York Academy of Sciences Disclosure: Nothing to disclose.

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