Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brethren Retirement Community during CMS and state inspections, most recent first.
A resident with a right lower leg skin tear had a physician order for daily cleansing and a band aid, but during observation the dressing removed was dated two days earlier. An RN verified the date and acknowledged she had worked the prior day and did not provide the ordered treatment. The resident had COPD, OA, CHF, anxiety, depression, and peripheral autonomic neuropathy, and had intact cognition with dependence for toileting hygiene, bed mobility, and transfers.
The facility did not employ a full-time DON dedicated solely to the skilled nursing facility, instead assigning the DON to oversee both the SNF and ALF. Interviews with staff and review of records confirmed that the DON has been responsible for both areas and could not specify the time spent on each, contrary to facility policy requiring a full-time DON for the SNF.
A resident with cognitive impairment and extensive care needs was subjected to neglect when a CNA used a washcloth contaminated with feces to wipe the resident's face. The incident was witnessed by a housekeeper, reported to an LPN, and confirmed by staff interviews and the CNA's own admission. The event was found to be in violation of the facility's abuse and neglect policy.
A resident with multiple health conditions was readmitted to a facility with a stage II pressure ulcer, but timely treatment was not initiated, leading to the ulcer worsening to stage III. Despite initial assessment, treatment orders were delayed until concerns were raised by the resident's representative. The facility's policies on wound care documentation and treatment were not followed, resulting in harm to the resident.
The facility failed to provide a dignified dining experience by not serving meals timely to residents in the dining room. Observations showed delays in serving three residents, with one leaving without a meal. Staff interviews confirmed the delay, and a resident's brother noted that dining room residents often wait over 45 minutes for meals.
A facility failed to maintain a clean and sanitary environment by not ensuring a resident's wheelchair was free of food particles. The wheelchair was observed to have a thick coating of food on the left side, which was confirmed by a CNA and the Chief Clinical Officer. The facility's policy required resident-care equipment to be cleaned, but this was not followed.
A facility failed to conduct required care conferences for a resident with severe cognitive impairment and multiple diagnoses, as confirmed by the resident's representative and the facility's administrator. The facility's policy supports resident participation in care planning, but this was not followed.
The facility failed to ensure pharmacy recommendations were reviewed by physicians and accurately documented, affecting two residents. One resident's records lacked documentation for a recommended GDR and dose titration, while another resident's GDR contraindications were inaccurately documented. The facility's policy requiring nursing management to review and process recommendations was not followed.
A facility failed to attempt or document a gradual dose reduction (GDR) for a resident's psychotropic medication as recommended by the pharmacy. The resident, with severe cognitive impairment and multiple diagnoses, was receiving duloxetine 60 mg daily. Despite a pharmacy recommendation for a GDR, there was no documentation of any attempt or completion of this process, confirmed by the Administrator.
A resident with hemiplegia and other conditions did not receive necessary rehabilitative services as per their care plan. Despite expressing a desire for therapy to improve daily living activities, the resident was not provided with therapy services, and there was no documentation of therapy refusals. The resident experienced a decline in mobility and increased atrophy, highlighting the facility's failure to ensure the resident's well-being.
The facility failed to implement proper infection control measures for residents on precautions. A resident with C. diff and HSV-1 lacked appropriate isolation signage, and gowns were improperly reused. Another resident with Influenza Type A was not on proper droplet precautions, and a CNA did not change her mask after room exit. A third resident with a pressure ulcer did not receive care under enhanced barrier precautions, as an LPN did not wear a gown during wound care. These actions violated the facility's infection control policies.
A resident reported being forcefully given Morphine by an agency LPN, but the facility's investigation was incomplete. The investigation did not include attempts to contact the alleged perpetrator or interview other potential witnesses, contrary to the facility's policy. The neglect allegation was substantiated based solely on the resident's interview.
Wound treatment order not completed as directed
Penalty
Summary
Failure to provide wound treatment as ordered occurred for one resident with a right lower leg skin tear. The resident was admitted on 01/31/25 and had diagnoses including COPD, osteoarthritis, CHF, anxiety, depression, and peripheral autonomic neuropathy. The annual MDS indicated a BIMS score of 14, with the resident independent with eating and dependent on staff for toileting hygiene, bed mobility, and transfers. A physician order dated 04/29/26 directed staff to cleanse the skin tear on the right lower leg with wound cleanser and apply a band aid daily. During observation of a dressing change on 05/19/26 at 12:28 P.M., the bandage removed from the right lower leg was dated 05/17/26. RN #104 verified the date on the dressing and acknowledged she had worked the previous day and did not provide the treatment as ordered. The facility policy stated wound treatments would be provided in accordance with physician orders, including cleansing method, dressing type, and frequency.
Failure to Employ Full-Time DON for Skilled Nursing Facility
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) solely for the skilled nursing facility (SNF), as required. Staff interviews confirmed that the DON has been responsible for both the SNF and the assisted living facility (ALF) for the past two years, and the DON herself was unable to specify how much time she spends on each area weekly. The Licensed Nursing Home Administrator and Director of Human Resources both confirmed that the DON was officially assigned to oversee both the SNF and ALF full time. Review of facility policy and the DON job description indicated that the DON is expected to assume full authority, responsibility, and accountability for nursing services in the facility, and that a registered nurse should be designated as DON on a full-time basis for the SNF. This deficiency had the potential to affect all 71 residents in the facility.
Neglect: Resident's Face Wiped with Feces-Contaminated Cloth
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) used a washcloth that had been used to wipe feces from a bed pad to then wipe a resident's face. The resident involved had Alzheimer's disease and dementia, was cognitively impaired, and required extensive assistance with personal hygiene. The incident was witnessed by a housekeeper, who observed the CNA wiping feces from the bed and then using the same cloth on the resident's face, after which the resident was seen crying. Multiple staff statements confirmed the sequence of events. The housekeeper reported the incident to another CNA, who then informed an LPN. The CNA involved admitted to the action, stating it was accidental and attributed her distraction to personal distress. The LPN assessed the resident and found no injury or redness. The incident was reported to the DON and the administrator, and the CNA was immediately removed from the floor pending investigation. The facility's investigation substantiated that neglect had occurred. The CNA's actions were in direct violation of the facility's abuse, neglect, and exploitation policy, which prohibits such conduct and requires staff to prevent and report abuse or neglect. The incident was documented in a self-reported incident and corroborated by multiple staff witness statements and interviews.
Failure to Timely Initiate Pressure Ulcer Care
Penalty
Summary
The facility failed to initiate timely pressure ulcer care treatments and conduct thorough wound assessments for a resident, leading to the worsening of a pressure ulcer. The resident, who had multiple diagnoses including diabetes mellitus and congestive heart failure, was readmitted to the facility with a stage II pressure ulcer on the coccyx. Despite the initial assessment noting the ulcer, no treatment orders were implemented until the resident's representative raised concerns several days later. This delay resulted in the ulcer worsening to a stage III, with increased slough and drainage. The medical record review revealed a lack of documentation for wound care treatment orders on the date of readmission, and no full assessment of the wound was conducted between the initial identification and a subsequent evaluation. The facility's policies required thorough documentation and timely treatment orders, which were not adhered to in this case. The Director of Nursing confirmed the absence of documentation and assessments, acknowledging the failure to initiate treatment promptly and the subsequent deterioration of the resident's condition.
Delayed Meal Service in Dining Room
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in the 500 Hall dining room by not providing meals in a timely manner. Observations revealed that staff began assisting residents to the dining room and serving drinks at 11:37 A.M., but did not start serving lunch trays until 12:04 P.M. Out of ten residents present, three residents did not receive their lunch trays while others were already eating or had finished their meals. Specifically, one resident received their meal at 12:40 P.M., another received part of their meal at 12:44 P.M. and the remainder at 12:46 P.M., while the third resident left the dining room without receiving a meal tray by 1:13 P.M. Interviews with staff confirmed the delay in serving meals to the three residents compared to others in the dining room. A Licensed Practical Nurse acknowledged that meal trays were served to residents in their rooms before all residents in the dining room were served. A Dietary Aide also confirmed the delay in serving the three residents. Additionally, a resident's brother reported that residents who eat in the dining room typically wait 45 minutes or more to be served once they are seated.
Failure to Maintain Clean Wheelchairs
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, specifically in the maintenance of wheelchairs. During an observation, it was noted that a resident's wheelchair was covered with a thick coating of food particles on the left side, affecting the lower rails and the seat cushion. This observation was confirmed by a Certified Nurse Aide (CNA), who stated that it was the responsibility of the third shift CNAs to clean the wheelchairs. Further verification of the wheelchair's condition was provided by the Chief Clinical Officer. A review of the facility's policy on cleaning and disinfection of resident-care equipment indicated that such equipment should be cleaned, yet this was not adhered to in this instance.
Failure to Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted as required for a resident. The medical record review for a resident revealed that there was no documentation of a care conference since the initial one held in June 2024. This resident, who was admitted with diagnoses including dementia, osteoarthritis, congestive heart failure, and chronic kidney disease stage III, had severely impaired cognition and required varying levels of staff assistance for daily activities. An interview with the resident's representative confirmed that the facility had not held a care conference in a long time. The facility's policy supports the resident's right to participate in care planning, but this was not adhered to in this case, as confirmed by the facility's administrator.
Failure to Review and Accurately Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the physician and that physician responses to these recommendations were accurate, affecting two residents. For Resident #11, the medical record showed a lack of documentation supporting that the facility completed a gradual dose reduction (GDR) for the antidepressant medication mirtazapine and duloxetine as recommended by the pharmacy. Additionally, there was no evidence that the physician reviewed a pharmacy recommendation to titrate the memantine dose. The facility's administrator confirmed the absence of documentation for these pharmacy recommendations. For Resident #31, the facility inaccurately documented the reasons for contraindicating a GDR of antianxiety medications lorazepam and buspirone. The documentation claimed previous attempts at GDR caused symptom recurrence, but the resident had not been at the facility long enough for such attempts to have been made. The Chief Clinical Officer confirmed the inaccuracy of the GDR responses. The facility's policy required nursing management to review signed recommendations and process any orders, which was not adhered to in these cases.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that recommendations for gradual dose reductions (GDR) of psychotropic medications were attempted or completed as required for a resident. This deficiency was identified during a review of the medical record for a resident who was admitted with multiple diagnoses, including dementia, Parkinson's disease, asthma, COPD, depression, and anxiety. The resident's quarterly Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a need for varying levels of assistance with daily activities. The resident was receiving antipsychotic and antidepressant medications, including duloxetine 60 mg daily. A pharmacy recommendation dated July 17, 2024, suggested a GDR for the resident's duloxetine medication. However, there was no documentation in the medical record to support that the facility completed or attempted the GDR as recommended. An interview with the Administrator confirmed the lack of documentation for the GDR attempt or completion. The facility's policy, titled Medication Regimen Review Practice Guide, indicated that nursing management should review and process signed recommendations, but this was not adhered to in this case.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to a resident as required by their comprehensive plan of care. The resident, who was admitted with diagnoses including hemiplegia following a stroke, depression, type two diabetes mellitus, and congestive heart failure, was cognitively intact but required assistance with activities of daily living such as eating, toileting hygiene, bed mobility, and transfers. The care plan indicated a need for physical therapy consultation for strength and mobility, yet there was no evidence of therapy being provided despite the resident's expressed desire for assistance to improve activities of daily living. Interviews with the Director of Rehabilitation Services and the Director of Nursing revealed that the resident had refused therapy services on multiple occasions, with the last evaluation occurring several months prior. However, there was no documentation of these refusals, and the Certified Nurse Practitioner was unaware that therapy had not been offered in the resident's room. The resident was observed to have a decline in mobility and increased atrophy of the left arm, indicating a lack of necessary rehabilitative services to maintain or restore their highest practicable level of well-being.
Inadequate Infection Control Measures for Residents on Precautions
Penalty
Summary
The facility failed to ensure proper infection control measures were in place for residents on infection control precautions. Resident #179, who was admitted with a diagnosis of Clostridium difficile (C. diff) and herpes simplex virus (HSV-1), did not have appropriate signage indicating isolation precautions on or near their room. A Certified Nurse Aide (CNA) confirmed the absence of signage and later placed a sign on the door. Additionally, gowns were found hanging in the room, which were not supposed to be reused, and there was no container for soiled linens. The Director of Nursing (DON) confirmed that transmission-based precautions should have been initiated upon the resident's admission. Resident #38, who tested positive for Influenza Type A, was supposed to be on droplet precautions. However, the sign on the door only indicated enhanced barrier precautions, and a CNA was observed entering and exiting the room without changing her surgical mask, contrary to droplet precaution protocols. The DON was unaware that droplet precautions had not been properly initiated for this resident. Resident #12, who had a stage III pressure ulcer, was supposed to be under enhanced barrier precautions, which require the use of a gown and gloves during high-contact care activities. An LPN was observed performing wound care without wearing a gown, and confirmed that staff did not wear gowns for wound or incontinence care. The facility's policy on enhanced barrier precautions was not followed, as it mandates gown and glove use for residents with wounds or indwelling devices to prevent the transmission of multidrug-resistant organisms.
Incomplete Investigation of Alleged Neglect Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged neglect incident involving a resident who reported being forcefully administered Morphine by an agency LPN. The resident, who was cognitively intact and had multiple medical conditions including cerebral infarction and atrial fibrillation, expressed that she did not want the Morphine due to its effects. Despite the resident's report, the facility's investigation was incomplete, as it did not include attempts to contact the alleged perpetrator or identify and interview other individuals who might have knowledge of the incident. The facility's policy on Abuse, Neglect, and Exploitation requires identifying and interviewing all involved persons and providing complete documentation of the investigation. However, the investigation file lacked documentation of efforts to contact the alleged perpetrator or other potential witnesses. The facility substantiated the neglect allegation based solely on the resident's interview, without fulfilling the policy's requirements for a comprehensive investigation. This deficiency was confirmed by the Administrator during an interview.
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Illustrative
What surveyors actually found near you
We read the 155 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ayden Healthcare Of Greenville | 1.7 mi | ★★★★★ | 12 | 0 |
| Rest Haven Nursing Home Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Village Green Rehabilitation And Healthcare Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Union City Care Center | 11.3 mi | ★★★★★ | 2 | 0 |
| Versailles Rehabilitation And Health Care Center | 11.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.