Above 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 Grace Brethren Village during CMS and state inspections, most recent first.
A resident with multiple medical conditions was administered discontinued medications and the incorrect form of aspirin, resulting in a medication error rate of 10.3%. Nursing staff failed to follow current physician orders and facility policy, leading to the administration of Colace and tamsulosin after discontinuation, and substituting aspirin 81 mg for the prescribed aspirin-dipyridamole.
A resident with multiple medical conditions was given aspirin 81 mg by an RN instead of the prescribed aspirin-dipyridamole (Aggrenox), as observed during a medication pass. The nurse confirmed the error, and review of facility policy showed required verification steps were not followed, resulting in a significant medication error.
A resident with multiple health issues, including dementia and osteoporosis, fell out of bed and sustained a thoracic compression fracture due to inadequate fall prevention measures. Despite being at risk for falls, the facility did not implement sufficient interventions, and staff were unaware of the resident's tendency to lean to one side, leading to the incident.
The facility failed to provide adequate supervision and use of assistive devices, resulting in falls for several residents. A resident with Parkinson's was left unsupervised, another with dementia wore improper footwear, and a third with hemiplegia fell after raising his bed. Additionally, a resident fell during a transfer due to the absence of a gait belt, contrary to facility policy. These incidents highlight lapses in adherence to care plans and safety protocols.
A facility failed to update a resident's code status in the electronic medical record, despite the resident's clear wishes and an updated order signed by a Family Nurse Practitioner. The resident, with multiple serious health conditions, wanted to change her status from DNRCCA to DNRCC due to concerns about potential injuries from chest compressions. The discrepancy was confirmed through interviews, revealing non-compliance with the facility's policy on code status communication.
A facility failed to inform a resident about the last covered day of skilled services, as required for Medicaid/Medicare coverage notices. The resident, who was alert and oriented, did not receive a Notice of Medicare Non-Coverage (NOMNC) or verbal communication about the coverage end date. The Admission Nurse notified the resident's daughter but not the resident, and later acknowledged the oversight. The facility lacked a policy for NOMNC notifications.
The facility failed to provide bed hold notices to residents or their representatives when transferred to the hospital, affecting three residents. Despite the facility's policy requiring written notice at the time of transfer, no such documentation was found in the medical records of the affected residents, as confirmed by the Chief Clinical Officer.
A facility failed to complete a discharge summary for a resident discharged home, missing key components such as a recapitalization of the stay, a final summary of status, and a post-discharge plan. The resident, with multiple diagnoses and severe cognitive impairment, required assistance with ADLs. An LPN confirmed the absence of the discharge summary, which was against the facility's policy requiring the interdisciplinary team to complete it.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 10.3%, which exceeds the acceptable threshold of less than 5%. Specifically, a resident with a history of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia was observed to have received medications that had been discontinued by physician order. Despite a pharmacy recommendation and a signed physician order to discontinue Colace and tamsulosin, these medications continued to be administered for several days. Additionally, the resident was given aspirin 81 mg instead of the prescribed aspirin-dipyridamole 25-100 mg tablet. During medication administration observation, a registered nurse prepared and administered Colace, tamsulosin, and aspirin 81 mg to the resident, contrary to the current physician orders. Interviews with nursing and clinical leadership confirmed that the discontinued medications were still being given and that the wrong form of aspirin was administered. Review of facility policy indicated that staff are required to verify medication orders and ensure correct administration, but these procedures were not followed, leading to the identified medication errors.
Significant Medication Error Due to Incorrect Drug Administration
Penalty
Summary
A deficiency was identified when a resident with a history of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia was administered the incorrect medication. The resident had a physician's order for aspirin-dipyridamole (Aggrenox) 25-100 mg to be given twice daily, but there was no order for aspirin 81 mg daily. During a medication pass observation, a registered nurse prepared and administered aspirin 81 mg instead of the prescribed aspirin-dipyridamole. The nurse confirmed during an interview that the incorrect medication was given. Review of the facility's policy on administering oral medications indicated that staff are required to verify the physician's order, check the medication label, and confirm the medication name and dose with the Medication Administration Record (MAR). The failure to follow these procedures resulted in a significant medication error for the resident.
Failure to Prevent Resident Fall Resulting in Injury
Penalty
Summary
The facility failed to prevent a resident from falling out of bed, resulting in actual harm when the resident was transferred to the hospital with a thoracic compression fracture. The resident, who had multiple diagnoses including dementia, diabetes, and osteoporosis, was at risk for falls due to balance problems, muscle weakness, and lack of coordination. The care plan included interventions such as ensuring the call light was within reach and providing extensive assistance for turning and repositioning in bed. However, these interventions were not sufficient to prevent the fall. The incident report revealed that the resident was found face down on the floor between her bed and recliner, and was later diagnosed with a fracture. Interviews with staff indicated that the resident required significant assistance with positioning and often slid to the left side of the bed. Despite this, there were no interventions in place to prevent the resident from falling out of bed, and the Interim DON was unaware of the resident's leaning issue. The facility's policy on managing falls required staff to identify interventions based on the resident's specific risks, which was not adequately done in this case.
Inadequate Supervision and Assistive Device Use Leads to Falls
Penalty
Summary
The facility failed to ensure adequate supervision and use of appropriate assistive devices to prevent falls for several residents. Resident #4, diagnosed with Parkinson's disease and vascular dementia, was identified as high risk for falls and required maximum staff assistance with ambulation. Despite this, the resident was observed alone in the dining room without supervision, contrary to the care plan that specified the resident should not be left alone in common areas. This lack of supervision was confirmed by an LPN. Resident #11, with cerebral vascular disease and dementia, was also at high risk for falls and required proper footwear as an intervention. However, the resident was observed wearing regular socks instead of the prescribed shoes and socks or nonskid socks, which was confirmed by an LPN. This oversight increased the risk of falls, especially given the resident's severe cognitive impairment and tendency to stand without assistance. Resident #34, with hemiplegia and cognitive impairment, experienced a fall after raising his bed to a high position, despite interventions like fall mats and a low bed position being in place. The fall resulted in a hospital admission due to a head injury. The facility's investigation did not include new interventions to prevent further falls, as confirmed by the DON. Additionally, Resident #21, who required substantial assistance for mobility, fell during a transfer because the aide did not use a gait belt, which was standard practice for residents needing assistance. This was confirmed by the DON, highlighting a failure to adhere to the facility's policy on gait belt use.
Failure to Update Resident's Code Status in Electronic Medical Record
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately updated and reflected in the electronic medical record. This deficiency affected a resident who was admitted with multiple serious health conditions, including congestive heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and multiple myeloma. The resident had a physician's order for a Do Not Resuscitate Comfort Care Arrest (DNRCCA) status, but later expressed a desire to change this to Do Not Resuscitate Comfort Care (DNRCC) due to concerns about the potential for broken bones during chest compressions. Despite the resident's clear wishes and the updated order signed by a Family Nurse Practitioner, the electronic medical record was not updated to reflect the change from DNRCCA to DNRCC. Interviews with the resident and the Director of Nursing confirmed the discrepancy in the code status documentation. The facility's policy on Communication of Code Status, which requires the nurse to ensure that the code status is updated correctly in all sections of the resident's medical record, was not followed. This oversight resulted in the resident's code status being inaccurately recorded in the electronic medical record, despite being correctly documented in the hard chart. The failure to update the electronic medical record could have led to actions contrary to the resident's wishes in the event of a medical emergency.
Failure to Communicate Last Covered Day of Skilled Services
Penalty
Summary
The facility failed to communicate the last covered day of skilled services to a resident, which is a requirement for providing proper notice of Medicaid/Medicare coverage and potential liability for services not covered. This deficiency affected a resident who was admitted with diagnoses including aftercare following joint replacement surgery, hypertension, and dementia. The resident had moderate cognitive impairment but was alert, oriented, and able to make her own decisions. Despite these capabilities, the resident did not receive a Notice of Medicare Non-Coverage (NOMNC) or verbal communication regarding the last covered day of skilled services. The Admission Nurse (AN) documented notifying the resident's daughter by telephone about the last covered day, but failed to provide the NOMNC to the resident herself. An interview with the resident confirmed that she was not informed about the NOMNC or the last covered day. The AN later acknowledged the oversight and apologized to the resident, subsequently providing the NOMNC and obtaining the resident's signature. The Chief Clinical Officer confirmed that the facility lacked a policy for the notification of NOMNCs, contributing to the communication failure.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital, affecting three residents. Resident #2, who was moderately cognitively impaired and required assistance with activities of daily living, was transferred to the hospital for evaluation and treatment on 12/28/24, but no bed hold notice was documented in their medical record. Similarly, Resident #11, who was severely cognitively impaired, was transferred to the hospital after a fall on 08/06/24, and Resident #26, who was cognitively intact but required assistance with ADLs, was sent to the hospital for respiratory distress on 12/18/24. Both residents also lacked documented bed hold notices in their medical records. The Chief Clinical Officer confirmed that the facility did not provide bed hold notices to the affected residents or their representatives upon transfer to the hospital. The facility's policy, dated October 2024, required that a written notice specifying the duration of the bed hold policy and information about returning to the next available bed be provided at the time of transfer. However, this policy was not followed, resulting in the deficiency noted in the report.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for Resident #39, who was discharged home. The medical record review and staff interview revealed that the discharge summary was missing essential components, including a recapitalization of the resident's stay, a final summary of the resident's status, and a post-discharge plan. Resident #39 had been admitted with diagnoses such as chronic kidney disease, sick sinus syndrome, hypertension, osteoarthritis, and traumatic subdural hemorrhage. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and required assistance with activities of daily living. Despite these needs, the discharge summary was not completed, as confirmed by an interview with an LPN. The facility's policy required the interdisciplinary team to complete the discharge summary, including medication reconciliation and a post-discharge care plan, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 538 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Englewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Pointe Health Campus | 0.8 mi | ★★★★★ | 6 | 0 |
| Englewood Health And Rehab | 1.4 mi | ★★★★★ | 0 | 0 |
| Arc At Trotwood Llc | 2.3 mi | ★★★★★ | 15 | 0 |
| Aventura At Shiloh Springs | 2.9 mi | ★★★★★ | 20 | 0 |
| Trotwood Health & Rehab Llc | 3.2 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Grace Brethren Village.
100% money-back within 48 hours.
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.