Cycle 1
Health 2024-11-21 · Fire 2024-11-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Brookville, OH
Brookhaven Nursing & Rehabilitation Center
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
One Country Lane, Brookville, OH
(937) 833-2133
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1979-10-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,705
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.17
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.66
Baseline 21.58% · Performance 19.73% · Measure score 3.66 · Achievement 3.66 · Improvement 3.55
Healthcare-associated infections
4.92
Baseline 6.31% · Performance 6.36% · Measure score 4.92 · Achievement 4.92 · Improvement 0
Total nurse turnover
6.68
Baseline 53.04% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 5.42
Adjusted total nurse staffing
4
Baseline 4.57 hours · Performance 4.22 hours · Measure score 4 · Achievement 4 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 9.09% · Lower 95% interval 7.05% |
| Discharge to community | 62.15% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 145 · Observed rate 55.86% · Lower 95% interval 55.45% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.1% |
95.27%
0.8 pts better
|
Numerator 74 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 72.22% |
53.69%
18.5 pts better
|
Numerator 39 · Denominator 54 |
| Discharge mobility score | 70.37% |
50.94%
19.4 pts better
|
Numerator 38 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 3 · Denominator 77 · Adjusted rate 3.98% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 5.91% |
8.2%
2.3 pts worse
|
Numerator 12 · Denominator 203 |
| Staff flu vaccination coverage | 31.78% |
42%
10.2 pts worse
|
Numerator 68 · Denominator 214 |
| Discharge function score | 75.93% |
56.45%
19.5 pts better
|
Numerator 41 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 29.27% |
25.2%
4.1 pts better
|
Numerator 12 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.3%
1.3 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.0% · Q3 4.2% · Q4 5.3% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.0% |
26.1%
21.1 pts better
|
11.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.8% · Q3 3.0% · Q4 4.5% · 4Q avg 5.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.2%
2.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.6% · Q3 1.9% · Q4 3.6% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
25.4%
7.3 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 13.0% · Q3 20.4% · Q4 21.4% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
11.5%
0.2 pts worse
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 12.8% · Q3 8.3% · Q4 10.6% · 4Q avg 11.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.2% |
7.7%
2.5 pts worse
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
6.2%
1 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 0.0% · Q3 2.2% · Q4 6.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.5%
0.6 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
21.7%
3 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 23.7% · Q3 21.6% · Q4 30.2% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
3.7%
0.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 3.2% · Q3 2.8% · Q4 2.6% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
78.1%
20.8 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.0% · Q3 98.9% · Q4 98.2% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
12.5%
1.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 12.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 0.9% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
75.6%
23 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
25.1%
5.2 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 18.3% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-02 · Fire 2021-09-02
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-11-21 · Fire 2019-11-21
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
F · Potential for more than minimal harm
2024-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-13
F · Potential for more than minimal harm
2021-09-02
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-11-11
F · Potential for more than minimal harm
2021-09-02
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2021-11-11
E · Potential for more than minimal harm
2021-09-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-11-11
E · Potential for more than minimal harm
2021-09-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-11-11
E · Potential for more than minimal harm
2021-09-02
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 2021-11-11
E · Potential for more than minimal harm
2021-09-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-11-11
F · Potential for more than minimal harm
2019-11-21
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2020-01-03
F · Potential for more than minimal harm
2019-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2020-01-03
C · Minimal harm
2019-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-01-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-21
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 2024-12-13
D · Potential for more than minimal harm
2024-11-21
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 2024-12-13
D · Potential for more than minimal harm
2024-11-21
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 2024-12-13
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-05-08
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 2024-05-24
F · Potential for more than minimal harm
2021-09-02
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 2021-11-11
D · Potential for more than minimal harm
2021-09-02
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2021-11-11
F · Potential for more than minimal harm
2019-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-03
F · Potential for more than minimal harm
2019-11-21
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
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 2020-01-03
D · Potential for more than minimal harm
2019-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-11-21
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 2020-01-03
Penalties and ownership
What sits behind the stars
Ownership
United Church Homes, Inc.
5% Or Greater Direct Ownership Interest · Organization
Jackson, Shirley
5% Or Greater Direct Ownership Interest · Individual
Howett, Bryan
5% Or Greater Direct Ownership Interest · Individual
Hcf Management, Inc.
Operational/Managerial Control · Organization
Miller, Terry
Corporate Director · Individual
Miller, Terry
Corporate Officer · Individual
Nelson, Denise
Corporate Director · Individual
Nelson, Denise
Corporate Officer · Individual
Prunier, Kenneth
Corporate Director · Individual
Prunier, Kenneth
Corporate Officer · Individual
Smith, Christy
W-2 Managing Employee · Individual
Unverferth, Chad
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Englewood Health And Rehab
Englewood, OH
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Aventura At Shiloh Springs
Trotwood, OH
2-star overall rating with 1-star inspections with $8,469 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
New Lebanon Rehabilitation And Healthcare Center
New Lebanon, OH
1-star overall rating with 1-star inspections with $96,413 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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