Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Brown Memorial Home Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses developed bruising and swelling on the lower left extremity, which was observed by a hospice shower aide. Facility staff did not document the size, location, or description of the bruise, nor did they monitor or record changes in the condition over time, despite policy requiring regular skin assessments and documentation of new skin issues. Leadership confirmed the absence of documentation and monitoring for the identified bruise.
Failure to complete pharmacy GDR review: A resident with multiple chronic conditions and intact cognition was receiving Wellbutrin and Citalopram for depression, but monthly pharmacy reviews over 13 months contained no GDR recommendations for either medication. The DON and new DON confirmed the recommendations were absent, and the facility did not have psychiatric notes to support a GDR review.
Failure to Follow Midodrine BP Parameters: Two residents had Midodrine orders that were not followed as written. For one resident with orthostatic hypotension, dementia, Parkinson’s disease, and repeated falls, staff repeatedly held the medication without obtaining or documenting BP/vital signs and also gave it when BP was above the hold parameters. For another resident with multiple cardiac, respiratory, neurologic, and psychiatric diagnoses, the PRN Midodrine order for SBP below 100 mm Hg was never administered despite documented low BP readings.
Exhaust fans in both the front and back shower rooms were not working, as confirmed by the DON and Maintenance Supervisor. A mildew-like substance was present on the ceiling around the exhaust fan in the back shower room. No records or receipts showed that parts had been ordered to repair or replace the fans, potentially affecting all 33 residents using the shower rooms.
The facility failed to date opened food items in the refrigerator and freezer, as observed during a kitchen tour. Items included various condiments, deli meats, and frozen goods. This practice, confirmed by the DM, did not comply with the facility's policy requiring labels with product names and dates, potentially affecting all 39 residents.
A resident was not provided with an Advanced Beneficiary Notice (ABN) when discharged from Medicare Part A services but remained in the facility. The Business Office Manager confirmed the oversight, stating she was unaware of the requirement. The facility's policy mandates timely notices regarding Medicare coverage, which was not adhered to, leaving the resident uninformed about potential liability for non-covered services.
A facility failed to document a resident's transfer to the hospital due to a change in condition. The resident had a complex medical history and was dependent on staff for most daily activities. The electronic medical record lacked progress notes or assessments explaining the hospitalization, which was confirmed by the DON. This affected one of three residents reviewed for hospitalization, with a facility census of 39.
The facility did not notify the local Ombudsman of the transfers and discharges of two residents, as required by policy. One resident with congestive heart failure was hospitalized twice, and another with dementia was discharged to the hospital twice. The DON confirmed the lack of notification to the Ombudsman for these events.
The facility failed to notify two residents of the number of bed hold days remaining during hospital transfers, as required by policy. One resident with congestive heart failure and another with multiple diagnoses, including dementia, were affected. The Director of Nursing confirmed the omission of this information in the bed hold notices.
The facility failed to update PASRR documents for two residents who received new mental health diagnoses. One resident's PASRR was not updated to include a new diagnosis of paranoid schizophrenia, while another resident's PASRR did not reflect additional diagnoses of bipolar disorder, schizoaffective disorder, and anxiety disorder. These omissions were confirmed by facility staff.
A resident's care plan was not updated after being discharged from hospice care and experiencing significant weight gain. Despite a dietitian's recommendation to reduce milk intake, the care plan continued to include hospice-related interventions and outdated nutritional orders. Interviews confirmed the care plan should have been revised to reflect the resident's current health status.
A resident with a history of falls and a diagnosis of atherosclerotic heart disease did not have care planned fall prevention measures in place. Observations revealed the resident lacked non-skid socks, a parameter mattress, a low bed position, and a floor mattress. The DON confirmed these interventions were not implemented.
A facility failed to document the BiPAP settings in a physician's order for a resident with respiratory issues. The resident, who had several medical conditions, used a BiPAP machine, but the order incorrectly specified a CPAP machine. Interviews revealed that the specific BiPAP settings were not known or documented, contrary to facility policy.
The facility failed to obtain proper parameters for as-needed pain medications for two residents, leading to unnecessary drug administration. One resident received Oxycodone and Acetaminophen without specified pain level parameters, while another received Oxycodone frequently without non-pharmacological interventions or physician notification when ineffective. The facility's policy on pain medication administration was not followed, resulting in the administration of unnecessary medications.
A resident with multiple medical diagnoses, including hypertension, did not receive their prescribed Losartan Potassium medication for four consecutive days, despite having blood pressure readings within the physician-ordered parameters. The DON confirmed the medication should have been administered, and the facility's policy did not address this issue.
A resident on a physician-ordered pureed diet received food that was not prepared to the appropriate texture. The cook added excessive water to pureed pork chops, resulting in a stringy and watery consistency. Despite attempts to correct the texture, the Dietary Manager had to substitute the meal with pureed chicken breasts.
Failure to Monitor and Document Skin Alterations
Penalty
Summary
The facility failed to adequately monitor and document skin issues, specifically bruising, for a resident with known skin alterations. The resident, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia, and was receiving palliative care, was noted by a hospice shower aide to have bruising and swelling on her lower left extremity. Despite this observation, there was no documentation in the progress notes regarding the measurement, description, or exact location of the bruising. Subsequent progress notes and weekly skin assessments did not include any information about the bruising or other skin injuries, and shower logs also lacked documentation to support ongoing monitoring of the reported skin issue. Interviews with facility leadership, including the DON, Administrator, and ADON, confirmed that there was no documentation to show that the bruising was monitored, measured, or described after it was initially identified. Review of the facility's skin assessment policy indicated that a full body skin assessment should be conducted upon admission, daily for three days, and weekly thereafter, as well as after any newly identified skin injury. However, there was no evidence that these procedures were followed in this case, and hospice records also lacked descriptive information about the bruise.
Failure to Complete Pharmacy GDR Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly drug regimen reviews, including review of the medical chart, in accordance with its policies and procedures for irregularity reporting. For Resident #20, who was admitted with diagnoses including GERD, emphysema, hyperlipidemia, morbid obesity, major depressive disorder, CHF, osteoarthritis, Type II DM, COPD, fibromyalgia, obstructive sleep apnea, HTN, vitamin D deficiency, and a history of falling, the MDS dated 09/14/25 showed she was cognitively intact. Review of her physician orders showed Wellbutrin 150 mg for depression initiated on 03/11/24 and Citalopram 10 mg, one-half tablet for depression, initiated on 12/06/23. Review of monthly pharmacy reviews from December 2024 through December 2025 showed no pharmacy recommendations related to a GDR for either medication during the 13 months reviewed. The DON and new DON confirmed there were no GDR recommendations for Wellbutrin or Citalopram and stated they should have been present, but the pharmacist indicated there was no indication for dose reduction at that time due to psychiatric notes/review; however, the current DON confirmed the facility did not have psychiatric notes to support a GDR recommendation or review in the last 12 months.
Failure to Follow Midodrine Blood Pressure Parameters
Penalty
Summary
The facility failed to monitor and administer Midodrine according to physician orders for two residents. Resident #11 had diagnoses including orthostatic hypotension, repeated falls, dementia, Alzheimer’s disease, Parkinson’s disease, and neurocognitive disorder with Lewy bodies. Her order for Midodrine 2.5 mg daily included parameters to hold the medication if SBP was greater than 90 mm Hg and DBP was greater than 50 mm Hg. Review of the MARs showed multiple dates in July, September, October, November, and December 2025 when the medication was held without a blood pressure being taken or without proper justification at the scheduled administration time. The same review also showed multiple dates when Midodrine was documented as administered even though the blood pressure was above the ordered hold parameters and the medication should have been held. The DON and new DON confirmed during interview that the medication had been held without vital signs being taken or documented at the time it was due, and that Midodrine had also been administered outside the physician’s parameters. They stated the physician had been contacted to clarify the parameters for the medication. Resident #5, admitted on 11/26/25, had diagnoses including myocardial infarction, chronic respiratory failure, Alzheimer’s disease, major depressive disorder, emphysema, bipolar disorder, vascular dementia, CHF, Type II DM, COPD, schizophrenia, and other psychiatric and neurologic conditions. The provider ordered Midodrine HCL 10 mg every 8 hours as needed for hypotension, to be given if SBP was less than 100 mm Hg. Review of documented blood pressures showed several readings below 100 mm Hg, but the MAR showed the medication was never administered when the ordered criteria were met. The DON confirmed the order had never been followed.
Non-Functional Shower Room Exhaust Fans and Mildew Observed
Penalty
Summary
The facility failed to maintain the shower room exhaust fans in good and working order, as confirmed by both observation and staff interviews. On the day of the survey, the exhaust fans in both the front and back shower rooms were found to be non-functional. A mildew-like substance was observed on the ceiling around the exhaust fan in the back shower room. The Director of Nursing (DON) was unable to provide evidence that parts had been ordered to repair or replace the fans, and the Maintenance Supervisor confirmed that no parts had been ordered prior to the survey date. This deficiency had the potential to affect all 33 residents identified as using the shower rooms.
Failure to Date Opened Food Items in Kitchen
Penalty
Summary
The facility failed to appropriately date opened food items in both the refrigerator and freezer, as observed during an initial tour of the kitchen. The items in the refrigerator included a large glass container of dill pickle spears, a large plastic container of mayonnaise, a plastic container of pimento cheese spread, a large plastic container of Pace Picante salsa, bottles of Frank's Red Hot sauce and Siracha hot sauce, small plastic containers of chicken and beef base, a small jar of minced garlic, a small jar of sliced jalapenos, a large plastic container of sour cream, a large plastic container of ham salad, a large plastic container of vanilla yogurt, a large jar of Concord grape jelly, and packages of sliced deli ham, salami, and turkey breast. These findings were confirmed by the Dietary Manager (DM) #106 during the observation. Additionally, the facility kitchen freezer contained opened items that were not dated, including a bag of frozen chicken tenders, a bag of frozen blueberries, a bag of frozen chicken breasts, a bag of frozen tator tots, and a bag of frozen fish patties. These findings were also confirmed by DM #106. The facility's policy on refrigerated storage, which was undated, stated that refrigerated food should be stored in a manner that optimizes food safety and quality, and that items should bear a label indicating the product name and the date it was received, used, or first opened. The failure to adhere to this policy had the potential to affect all 39 residents residing in the facility.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident when he was discharged from Medicare Part A services but remained in the facility. This deficiency was identified during a review of the resident's records, the facility's beneficiary notice list, and interviews with staff. The resident, who had multiple medical diagnoses including traumatic amputation, dementia, and diabetes, was discharged from Medicare Part A therapy services on two occasions without receiving the required ABN. The Business Office Manager confirmed that the resident was not provided with an ABN and was unaware that it was necessary to do so. The facility's policy on Advance Beneficiary Notices states that timely notices regarding Medicare eligibility and coverage should be provided, and additional notices should be issued when appropriate. However, the policy was not followed in this case, as the resident did not receive an ABN when services were terminated, and he remained in the facility. The facility's failure to provide the ABN meant that the resident was not informed of his potential liability for services not covered by Medicare, nor was he given the opportunity to decide whether to continue receiving therapy services.
Failure to Document Resident Hospital Transfer
Penalty
Summary
The facility failed to document a resident transfer in the medical record when a resident was transferred to the hospital due to a change in condition. This deficiency was identified during a review of the medical records and staff interviews. The resident in question had a complex medical history, including conditions such as a fracture of the neck of the left femur, benign neoplasm of cerebral meninges, Pick's disease, dementia with severe mood disturbance, anxiety disorder, seizures, atrial fibrillation, major depressive disorder, mood disorder with depressive features, anxiety disorder, and insomnia. The resident was dependent on staff for most activities of daily living and was always incontinent of bladder and frequently incontinent of bowel. The review of the electronic medical record revealed that the resident was discharged and returned to the facility without any progress notes or assessments documenting the reason for the hospitalization. An interview with the Director of Nursing confirmed that there was no information in the medical record explaining the hospitalization, and it was expected that staff should document the reason for a resident's transfer to the hospital and complete an assessment of their condition. This lack of documentation affected one of the three residents reviewed for hospitalization, with the facility census being 39.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the local Ombudsman regarding the transfer and discharge of two residents, which is a requirement according to their policy. Resident #35, who had medical diagnoses including congestive heart failure and chronic obstructive pulmonary disease, was hospitalized on two occasions and had unplanned discharges with return anticipated. The Director of Nursing (DON) confirmed that the Ombudsman was not notified of these hospitalizations or discharges, despite the facility's policy requiring such notification. Similarly, Resident #23, who had multiple diagnoses including dementia and anxiety disorder, was discharged to the hospital twice and returned to the facility. The DON acknowledged that there was no evidence of notification to the Ombudsman for these transfers. The facility's policy mandates that a copy of the transfer notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, which was not adhered to in these cases.
Failure to Notify Residents of Bed Hold Days
Penalty
Summary
The facility failed to notify two residents of the number of bed hold days remaining upon their transfer to the hospital, which is a requirement according to the facility's policy. Resident #35, who had medical diagnoses including congestive heart failure and chronic obstructive pulmonary disease, was hospitalized on two occasions. During these hospitalizations, the bed hold notices provided to the resident did not include the number of bed hold days remaining. This was confirmed by the Director of Nursing (DON) during an interview, acknowledging that the notices were incomplete. Similarly, Resident #23, who had multiple diagnoses such as a fracture of the neck of the left femur and dementia, was also transferred to the hospital twice. The bed hold notices for these transfers similarly lacked information on the remaining bed hold days. The DON confirmed this omission during an interview. The facility's policy mandates that residents or their representatives be informed in writing about the bed hold policies, including the duration of the bed hold, which was not adhered to in these cases.
Failure to Update PASRR Documents for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening Resident Review (PASRR) documents for two residents who received new mental health diagnoses. Resident #10, who was admitted with multiple diagnoses including vascular dementia, schizoaffective disorder, and major depressive disorder, received a new diagnosis of paranoid schizophrenia on 09/13/22. However, the PASRR document for this resident, last completed on 08/02/21, was not updated to reflect this new diagnosis. This oversight was confirmed during an interview with the Social Services Designee. Similarly, Resident #34, who was admitted with diagnoses such as cervicalgia, anxiety disorder, and bipolar disorder, had her PASRR document last updated on 06/29/23. This document failed to include several mental health diagnoses that were added to her medical record, including bipolar disorder, schizoaffective disorder, and anxiety disorder. The Director of Nursing confirmed that the PASRR documents were not updated to include these diagnoses, as verified during a discussion with the social services director.
Failure to Update Care Plan After Significant Change in Resident's Condition
Penalty
Summary
The facility failed to revise the care plan for a resident when significant changes in her condition occurred. The resident, who was admitted with multiple diagnoses including cervicalgia, anxiety disorder, and schizoaffective disorder, was discharged from hospice care in February 2024 due to improved health conditions, including weight gain. Despite this change, her care plan continued to include interventions related to hospice care, such as honoring comfort care desires per hospice protocol and providing eight ounces of chocolate or strawberry milk with all meals. A dietitian recommended reducing the resident's milk intake from eight ounces to four ounces due to significant weight gain, but this change was not reflected in the care plan. Interviews with the Director of Nursing and the dietitian confirmed that the care plan should have been updated to reflect the resident's current health status and nutritional needs. The failure to update the care plan affected the resident's care and was identified during a review of 15 resident care plans, with the facility census being 39.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that care planned assistance devices were properly placed to prevent falls for Resident #89, who was one of three residents reviewed for accident hazards. Resident #89 had a history of falls and was admitted with a diagnosis of atherosclerotic heart disease of the native coronary artery. The baseline care plan included interventions such as non-skid footwear, a parameter mattress, the bed in a low position, and a mattress on the floor to prevent falls. However, during observations on multiple occasions, Resident #89 was found in bed without non-skid tread socks, without a parameter mattress, with the bed not in a low position, and without a mattress on the floor. An interview with the Director of Nursing confirmed that the care planned interventions were not in place.
Failure to Document BiPAP Settings in Physician's Order
Penalty
Summary
The facility failed to ensure that the Bilevel Positive Airway Pressure (BiPAP) settings were included in the physician's order for a resident who required respiratory care. The resident, who had medical diagnoses including congestive heart failure, chronic obstructive pulmonary disease, secondary pulmonary arterial hypertension, and progressive systemic sclerosis, was admitted initially in August 2023 and readmitted in April 2024. The resident was cognitively intact and required partial to moderate assistance with some activities of daily living. The physician's order incorrectly specified the use of a Continuous Positive Airway Pressure (CPAP) machine with home settings, which was not the device the resident used. Interviews with the resident, the Director of Nursing (DON), and a Licensed Practical Nurse (LPN) revealed that the resident used a BiPAP machine, not a CPAP machine, and the specific settings for the BiPAP machine were not documented in the physician's order. The DON confirmed that the settings should have been included in the order, and the LPN acknowledged not knowing the specific settings for the machine. The facility's policy on verbal orders emphasized the importance of repeating orders back to the physician and entering them accurately into the medical record, which was not adhered to in this case.
Failure to Obtain Proper Parameters for PRN Pain Medications
Penalty
Summary
The facility failed to obtain proper parameters for as-needed pain medications for two residents, leading to the administration of unnecessary drugs. Resident #34, who was cognitively intact, had physician orders for Oxycodone and Acetaminophen without specified pain level parameters. The resident was administered Acetaminophen 16 times for pain levels of six and above and Oxycodone 15 times for pain levels of five or below, contrary to typical parameters. The Director of Nursing confirmed that parameters should be listed and that the facility's practice was to offer lower strength medication for pain levels one to five and higher strength medication for levels six to ten. Resident #29, with intact cognition and a history of chronic pain, was also affected by the lack of parameters for PRN pain medications. The resident received Oxycodone 32 times in July and 15 times in August for pain levels ranging from four to ten, with no evidence of non-pharmacological interventions being attempted prior to administration. The medication was noted to be ineffective on several occasions, yet there was no documentation of physician notification. Interviews with staff confirmed the absence of parameters and the lack of documentation for non-pharmacological interventions. The facility's policy on administering pain medications was not followed, as it required monitoring for medication effectiveness and adverse effects, conducting pain assessments, and evaluating non-pharmacologic interventions. The Director of Nursing confirmed the findings, acknowledging the absence of physician notification when medications were ineffective and the lack of parameters in physician orders. This oversight resulted in the administration of unnecessary medications without proper guidelines or documentation.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to administer blood pressure medication as ordered to a resident, identified as Resident #29, which constitutes a significant medication error. Resident #29, who was admitted on 10/18/21 and readmitted on 08/14/22, had medical diagnoses including essential primary hypertension, paroxysmal atrial fibrillation, morbid obesity, type II diabetes mellitus without complications, and anxiety disorder. The resident had intact cognition, scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, and required varying levels of assistance for Activities of Daily Living (ADLs). The Medication Administration Records (MAR) for August 2024 showed an order for Losartan Potassium 50 mg to be administered once daily for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 100. Despite the physician's order, the Losartan Potassium medication was held on four consecutive days (08/24/24, 08/25/24, 08/26/24, and 08/27/24) even though Resident #29's blood pressure readings were within the parameters set by the physician, with SBP readings of 110/62, 121/74, 108/68, and 110/62. An interview with the Director of Nursing (DON) confirmed that the medication should have been administered as the blood pressure readings were within the ordered parameters. The facility's policy on following physician orders was requested, but the provided policy titled 'Verbal Orders' did not address the administration of medications according to physician orders.
Inappropriate Texture of Pureed Food for Resident
Penalty
Summary
The facility failed to ensure that pureed food items were prepared at an appropriate texture for a resident who had a physician-ordered pureed diet. During an observation, a cook was seen preparing pureed pork chops by adding excessive amounts of hot water, resulting in a stringy and watery texture. The cook confirmed that the pureed pork chops were not of the appropriate texture and contained small gristly chunks, which were not suitable for serving to the resident. The cook acknowledged that the recipe for the breaded pork chops required only 1/4 cup of hot water per chop, but she had added 1/2 cup per chop, totaling approximately one cup of water. The Dietary Manager attempted to puree the pork chops again but was unable to achieve the correct texture, leading to a substitution with pureed chicken breasts. The facility's policy on puree food preparation emphasized the need for a smooth, thick paste consistency, which was not met in this instance.
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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.
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Nursing homes near Circleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pickaway Manor Care Center | 1.2 mi | ★★★★★ | 18 | 1 |
| Circleville Post-acute | 1.4 mi | ★★★★★ | 18 | 0 |
| Logan Elm Health Care Center | 2.3 mi | ★★★★★ | 6 | 0 |
| Hopewell Grove Rehabilitation And Healthcare | 17.2 mi | ★★★★★ | 10 | 1 |
| Luxe Rehabilitation And Care Center | 17.8 mi | ★★★★★ | 3 | 0 |
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