Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

GRACE BRETHREN VILLAGE

ENGLEWOOD, OH · 45 certified beds · Last Life Safety survey January 30, 2025

CMS Certification Number 366263 · first certified April 2003

Ownership

Independently operated (no chain recorded by CMS) · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

14 citations — more than 40% of the 922 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to September 2027. This facility’s last Life Safety survey was January 2025. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 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 three years in Maryland. 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 ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 14 citations on file is 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

E-0004

Physical environment (health survey)

5 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 14 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0584 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.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	14
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
February 27, 2020	4
March 31, 2022	7
January 30, 2025	3

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	2	2025-01-30
K-0711	Provide a written emergency evacuation plan.	2	2022-03-31
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2025-01-30
K-0712	Have simulated fire drills held at unexpected times.	1	2022-03-31
K-0324	Provide properly protected cooking facilities.	1	2022-03-31
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2022-03-31
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	1	2025-01-30
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	1	2020-02-27

What the citations cover

Citations by CMS category

Smoke Deficiencies 5
Miscellaneous Deficiencies 4
Gas, Vacuum, and Electrical Systems Deficiencies 3
Services Deficiencies 1
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	5
Miscellaneous Deficiencies	4
Gas, Vacuum, and Electrical Systems Deficiencies	3
Services Deficiencies	1
Emergency Preparedness Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 30, 2025 — 3 citations

Citations issued on January 30, 2025
Tag	What the surveyor checks	Status
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 28, 2025)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (March 28, 2025)
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 (March 28, 2025)

March 31, 2022 — 7 citations

Citations issued on March 31, 2022
Tag	What the surveyor checks	Status
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (May 6, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (May 6, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (May 6, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (May 6, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (May 6, 2022)
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 (May 6, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 6, 2022)

February 27, 2020 — 4 citations

Citations issued on February 27, 2020
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has plan of correction (April 15, 2020)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 15, 2020)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (April 15, 2020)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (April 15, 2020)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.