Grace Brethren Village
GRACE BRETHREN VILLAGE in ENGLEWOOD, OH — inspection on August 27, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on review of observations, staff interviews and review of facility policy, the facility failed to
two (#7 and #35) residents that were identified by the facility as being cognitively impaired, independently mobile and could access the unlocked/unsecured treatment cart.
The census was 39.
Findings include: Observation on 08/26/25 at 10:30 A.M. revealed a treatment cart located in a common area by the nursing station was unlocked and unsecured.
The treatment cart's drawers were able to be opened.
The treatment cart contained various medicated creams, powders, and solutions.
On 08/26/25 at 10:35 A.M. the Director of Nursing (DON) confirmed the treatment cart was unlocked, unsecured and contained contained various medicated creams, powders, and solutions.
The DON confirmed the treatment cart should be locked and only licensed staff should have access to the treatment cart.
Observation of the treatment cart contents with the DON on 08/26/25 at 3:25 P.M. revealed it contained eight 100 gram tubes of one percent (1%) diclofenac sodium cream (pain reliever), a tube of 3% lidocaine cream (pain reliever), a tube of clotrimazole and betamethasone dipropionate cream (antifungal), and two bottles of 3% hydrogen peroxide solution.
The facility identified two two (#7 and #35) residents that were cognitively impaired, independently mobile and that could access the unlocked/unsecured treatment cart.
Review of the facility's policy titled Storage of Medications dated revised November 2020 revealed the facility stores all drug and biologicals in a safe, secure, and orderly manner.
Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.
Unlocked medication carts are not to be left unattended.
This deficiency represents non-compliance investigated under Complaint Number 1395140 (OH00165817).
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.