Inspection visit
Fire Safety inspection
Citations
16 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0293GeneralS&S Fpotential for harm
Have properly located and lighted "Exit" signs.
- 0343GeneralS&S Epotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- 0344GeneralS&S Fpotential for harm
Have an alternate power supply for its alarm system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0914GeneralS&S Fpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0928GeneralS&S Fpotential for harm
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
FAQ · About this visit
Common questions about this visit
What happened during the September 2, 2021 survey of BROOKHAVEN NURSING & REHABILITATION CENTER?
This was a inspection survey of BROOKHAVEN NURSING & REHABILITATION CENTER on September 2, 2021. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BROOKHAVEN NURSING & REHABILITATION CENTER on September 2, 2021?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.