Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BROOKHAVEN NURSING & REHABILITATION CENTER
BROOKVILLE, OH · 99 certified beds · Last Life Safety survey April 16, 2026
CMS Certification Number 365422 · first certified October 1979
Ownership
Operated by UNITED CHURCH HOMES · For profit - Individual
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OH
18 citations — more than 58% of the 924 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 0 citations; the earlier surveys on file averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2027 — about 12 months from now. This facility’s last Life Safety survey was April 2026. Facilities in OH are typically surveyed 19–32 months after the last one (median 26), measured over 985 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 2, 2021 | 16 |
| November 21, 2024 | 2 |
| April 16, 2026 | 0 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-11-21 |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | 1 | 2021-09-02 |
| E-0036 | Establish emergency prep training and testing. | 1 | 2021-09-02 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2021-09-02 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2021-09-02 |
| K-0344 | Have an alternate power supply for its alarm system. | 1 | 2021-09-02 |
| E-0037 | Establish staff and initial training requirements. | 1 | 2021-09-02 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2021-09-02 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 21, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 13, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 13, 2024) |
September 2, 2021 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 11, 2021) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 11, 2021) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 11, 2021) |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Deficient, Provider has date of correction (November 11, 2021) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.