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Complaint Investigation

Grace Brethren Village

August 27, 2025 · Englewood, OH · 1010 Taywood Road
Citations 1
CMS Rating 2/5
Beds 45
Provider ID 366263
Healthcare Facility
Grace Brethren Village
Englewood, OH  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0761
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

Based on review of observations, staff interviews and review of facility policy, the facility failed to ensure a treatment cart containing medications was locked/secured.

This had the potential to affect 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 REPRESENTATIVE'S SIGNATURE

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ENGLEWOOD, OH, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRACE BRETHREN VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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