Brethren Retirement Community
Inspection Findings
F-Tag F0727
F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
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. Interview also confirmed she addresses concerns on the SNF and the AL as they arise and that she doesn't know how much time she spends on the SNF or the AL each week. Interview on 09/19/25 at 12:35 P.M. with the Licensed Nursing Home Administrator (LNHA) confirmed the DON is over the SNF and AL for the community full time. Interview also confirmed she has never been told the DON could not cover both buildings. Interview on 09/19/25 at 2:09 P.M. with the Director of Human Resources #314 confirmed the DON was given the position of DON over the SNF and AL on 06/12/25. Review of the Change of Status form revealed DON was given the DON position on 06/12/25.
Review of the Director of Nursing job description, undated revealed the Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the facility. Review of the Nursing Services - Registered Nurse policy, dated 04/2025 revealed the facility will designate a Registered Nurse to serve as the Director of Nursing on a full time basis.
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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BRETHREN RETIREMENT COMMUNITY in GREENVILLE, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 GREENVILLE, 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 BRETHREN RETIREMENT COMMUNITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.