01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-06 | 10 | 2025-03-06 | 4 |
| Cycle 2 | 2022-06-13 | 4 | 2022-06-13 | 5 |
| Cycle 3 | 2019-05-16 | 6 | 2019-05-16 | 3 |
CMS CCN 3650142026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Brethren Retirement Community
750 Chestnut Street · Greenville, OH 45331 · Darke County
Certified beds80CMS provider file
Recent citation rows32current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
32 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-19 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-06-10 · complaint2025-09-19 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Correction field: Deficient, Provider has date of correction · 2025-11-08 · complaint2025-04-14 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2025-03-20 · complaint2025-03-06 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0825Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-04-242025-03-06 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2025-04-142025-03-06 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-04-142024-06-18 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-07-30 · complaint2022-06-13 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · HEALTHF0888Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2022-07-292022-06-13 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2022-07-2903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-03-06 | Payment Denial | $0 | 22 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FIFTH THIRD BANK, NATIONAL ASSOCIATIONOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 09/01/2010
- ALLREAD, KARAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- EUBANK, CARLIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- GASPER, LISAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- HILL, HOLLYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- JAROS, FRANKIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- KEEN, JAMIIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 12/01/2021
- NEFF, PAMELAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- OVERFIELD, MELODYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- RANDOLPH, MICHAELIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 03/30/2010
- WARNER, JOHNIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 07/01/2007
- ARNOLD, MATTHEWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2010
- KELLER, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2011
- KEPLER, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2012
- RIESSER, LAWRENCEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2011
- WARNER, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2007
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.37per resident day
RN hours0.57per resident day
Weekend nurse hours3.76per resident day
Staff turnover51.5%CMS reported field
06 / LOCAL RECORDS
Open the Greenville ledger →