Cycle 1
Health 2025-11-21 · Fire 2025-11-21
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Milton, MA
Brush Hill Care Center
1-star overall rating with 2-star inspections with $196,683 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1200 Brush Hill Road, Milton, MA
(617) 333-0600
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
130
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1983-11-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.33
Nurse aide staffing
Weekend hours
3.51
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.9
0.5 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 42.2% |
92.2%
50 pts worse
|
93.4%
51.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
94.8%
3.6 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.5%
0.2 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
12.0%
10.2 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.2%
1.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.2% |
19.2%
3 pts better
|
19.6%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 21.7% |
22.5%
0.8 pts better
|
16.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.0% |
17.7%
10.3 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.8% |
17.6%
14.2 pts worse
|
14.9%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.0%
0.3 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.7% |
21.7%
5 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
4.6%
1.9 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 21.3% |
77.1%
55.8 pts worse
|
81.7%
60.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.8%
5.1 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.6% |
1.3%
3.3 pts worse
|
1.6%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.0% |
77.7%
45.7 pts worse
|
79.7%
47.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.0% |
25.8%
7.2 pts worse
|
23.9%
9.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-25 · Fire 2024-09-25
22 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-07-17 · Fire 2023-07-17
34 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-11-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-01-30
E · Potential for more than minimal harm
2024-09-25
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-09-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-09-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-11-14
C · Minimal harm
2024-09-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-14
C · Minimal harm
2024-09-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
F · Potential for more than minimal harm
2023-07-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-17
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-07-17
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-08-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-01
D · Potential for more than minimal harm
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-02
D · Potential for more than minimal harm
2025-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-02
F · Potential for more than minimal harm
2024-09-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-25
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-09-25
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-25
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-11-18
E · Potential for more than minimal harm
2024-09-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-04
C · Minimal harm
2024-09-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-01-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-09
D · Potential for more than minimal harm
2024-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-09
G · Actual harm
2023-07-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-29
G · Actual harm
2023-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-18
G · Actual harm
2023-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-29
F · Potential for more than minimal harm
2023-07-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-17
F · Potential for more than minimal harm
2023-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-07-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-07-17
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-17
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-29
E · Potential for more than minimal harm
2023-07-17
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-07-17
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-07-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-07-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-07-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-17
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-07-17
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-10-29
B · Minimal harm
2023-07-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-08-18
B · Minimal harm
2023-07-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-18
Penalties and ownership
What sits behind the stars
$3,418
2024-01-30
Fine
Fine · fine $3,418
Fine
$193,265
2023-07-17
Fine
Fine · fine $193,265
Fine
$0
2023-07-17
Payment Denial
Payment Denial · denial start 2023-10-17 · 115 days
115 day denial
Ownership
Klein, Gershon
5% Or Greater Direct Ownership Interest · Individual
Klein, Gershon
Operational/Managerial Control · Individual
Klein, Tibor
5% Or Greater Direct Ownership Interest · Individual
Milton Hc Operating LLC
5% Or Greater Direct Ownership Interest · Organization
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#2
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Mattapan, MA
2-star overall rating with 2-star inspections with 21 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
German Center For Extended Care
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5-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
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