Brethren Retirement Community

In the surveyor’s words

From the most serious findings on record at Brethren Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 6, 2025

  Based on medical record review, staff interview, and review of facility policies, the facility failed to ensure pressure ulcer care treatments were initiated timely and wound assessments were thoroughly completed to prevent the worsening of a pressure ulcer. Actual harm occurred to Resident #12 when the resident was readmitted to the facility with a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) on assessment and no treatment orders were implemented until concerns were voiced by the resident's representative several days later. This resulted in Resident #12's pressure ulcer worsening to a stage III pressure ulcer (full-thickness skin loss) and associated deterioration and drainage. This affected one (#12) of three residents reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF727Sep 19, 2025

  Based on staff interviews, employee record review, and policy review, the facility failed to employ a full time Director of Nursing (DON) for the skilled nursing facility. This had the potential to affect all 71 residents in the facility. Findings include: Interview on 09/19/25 with Licensed Practical Nurse (LPN) #448 confirmed the DON is over the skilled nursing and assisted living residents. Interview also confirmed the DON has been over the skilled nursing and assisted living residents for the past two years. Interview on 09/19/25 at 11:56 A.M. with the DON confirmed she has worked as the DON for the skilled nursing facility (SNF) and assisted living facility (ALF) full time since June 2025. […]

• No harm, potential for more than minimal, widespreadF888Jun 13, 2022

  Based on review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL, review of the COVID-19 staff vaccination status, review of staffing schedules, review of the list of COVID positive resident, staff interview, and review of the facility policy; the facility failed to ensure the staff COVID-19 vaccination rate was 100%. This had the potential to affect all 63 residents who resided in the facility. The census was 63. Findings include: Review of the undated facility COVID-19 staff vaccination status revealed the facility had a total of 160 employees. There were 117 employees fully vaccinated for COVID-19, 41 employees with exemptions and two employees who were not vaccinated for COVID-19 and did not have an exemption. […]

• No harm, potential for more than minimal, isolatedF684May 19, 2026

  Based on record review, observation, staff interview and review of facility policy,the facility failed to ensure wound treatment orders were completed as ordered. This affected one resident (#12) of three reviewed for wounds. The facility census was 67.Findings include:Review of medical record for Resident #12 revealed admission date of 01/31/25. The resident's medical diagnosis included Chronic Obstructive Pulmonary Disease (COPD), osteoarthritis, Congestive Heart Failure (CHF), anxiety, depression and peripheral autonomic neuropathy. The resident remained in the facility.The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. […]

• No harm, potential for more than minimal, isolatedF600Apr 14, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of self-reported incident (SRI), review of witness statements, review of in-service, review of employee file, review of corrective action, and review of policy, the facility failed to protect residents from neglect/physical abuse. This affected one (#1) of three residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record of Resident #1 revealed an admitted [DATE]. […]