Cycle 1
Health 2025-01-27 · Fire 2025-01-27
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Muskego, WI
Muskego Health And Rehabilitation Center
2-star overall rating with 2-star inspections with 26 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
S77 W18690 Janesville Rd, Muskego, WI
(262) 679-0246
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Champion Care
Operator or chain grouping
Approved since
2006-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
2.21
Nurse aide staffing
Weekend hours
3.34
Weekend nurse staffing
RN turnover
57%
Annual RN turnover
Total nurse turnover
67%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
95.7%
3 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.0%
2.2 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 68.1% |
5.0%
63.1 pts worse
|
11.4%
56.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.8% |
4.9%
0.9 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
16.6%
0.9 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
16.7%
7.1 pts better
|
16.7%
7.1 pts better
|
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 | 3.6% |
21.1%
17.5 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
17.3%
8.2 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
3.0%
2.2 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
25.5%
12 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.5%
1.6 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.3% |
86.8%
2.5 pts worse
|
81.7%
2.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
15.0%
7.7 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
82.2%
1.1 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.1% |
22.7%
16.4 pts worse
|
23.9%
15.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-28 · Fire 2023-09-28
28 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-27
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-27
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-26
E · Potential for more than minimal harm
2025-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-02-26
D · Potential for more than minimal harm
2025-01-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-26
F · Potential for more than minimal harm
2023-09-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-09-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-09-28
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-28
E · Potential for more than minimal harm
2023-09-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-09-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-28
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-10-17
C · Minimal harm
2023-09-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-31
C · Minimal harm
2023-09-28
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-10-17
F · Potential for more than minimal harm
2022-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-01
F · Potential for more than minimal harm
2022-06-08
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-07-01
F · Potential for more than minimal harm
2022-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-06
E · Potential for more than minimal harm
2022-06-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-08
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 2022-07-01
D · Potential for more than minimal harm
2022-06-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
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 2026-02-16
D · Potential for more than minimal harm
2025-12-03
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 2025-12-08
D · Potential for more than minimal harm
2025-12-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-12-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-08-04
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-04
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 2025-08-22
D · Potential for more than minimal harm
2025-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-02-25
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-25
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
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 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
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 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
E · Potential for more than minimal harm
2025-01-27
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 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
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 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-01-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-27
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 2025-02-27
D · Potential for more than minimal harm
2025-01-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-27
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 2025-02-27
D · Potential for more than minimal harm
2025-01-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-27
C · Minimal harm
2025-01-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-19
C · Minimal harm
2025-01-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-19
E · Potential for more than minimal harm
2024-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-18
E · Potential for more than minimal harm
2023-09-28
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
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 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-09-28
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 2023-10-24
D · Potential for more than minimal harm
2023-09-28
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 2023-10-24
C · Minimal harm
2023-09-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-24
B · Minimal harm
2023-09-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-24
E · Potential for more than minimal harm
2023-06-29
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 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-29
G · Actual harm
2022-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-08
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 2022-07-01
Penalties and ownership
What sits behind the stars
Ownership
Bay At Muskego Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ruvel, Menachem
5% Or Greater Indirect Ownership Interest · Individual
Weinberg, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Ruvel, Menachem
Operational/Managerial Control · Individual
Ruvel, Menachem
Corporate Director · Individual
Weinberg, Yisroel
Operational/Managerial Control · Individual
Weinberg, Yisroel
Corporate Director · Individual
Nearby options
Other facilities in reach
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Tudor Oaks Health Center
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1-star overall rating with 1-star inspections with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Complete Care at Hales Corners
Hales Corners, WI
4-star overall rating with 4-star inspections with $17,934 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Lindengrove New Berlin
New Berlin, WI
1-star overall rating with 1-star inspections with $125,115 in total fines with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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