Safety Report: Brethren Retirement Community
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
2Actual harm citations (severity G–I)
1Requirements cited on more than one inspection
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
2Abuse, neglect & exploitation
2Infection control
2Medications & pharmacy
1Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (9) than in the cycle before (5).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | May 19, 2026; May 16, 2019 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| March 6, 2025 | Payment Denial | Payment denial for 22 days, starting April 2, 2025 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
May 19, 2026 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected June 10, 2026
September 19, 2025 — 1 citation · complaint investigation
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · complaint · corrected November 8, 2025
April 14, 2025 — 1 citation · complaint investigation
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected March 20, 2025
March 6, 2025 — 8 citations (includes serious)
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · corrected April 14, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected April 24, 2025
D
Provide or get specialized rehabilitative services as required for a resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F825 · corrected April 14, 2025
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected April 14, 2025
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected April 14, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected April 14, 2025
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected April 14, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected April 14, 2025
June 18, 2024 — 1 citation · complaint investigation
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected July 30, 2024
June 13, 2022 — 3 citations
F
Ensure staff are vaccinated for COVID-19
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F888 · corrected July 29, 2022
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F812 · corrected July 29, 2022
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected July 29, 2022
May 16, 2019 — 5 citations (includes serious)
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected June 26, 2019
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected June 26, 2019
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected June 26, 2019
D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · corrected June 26, 2019
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected June 26, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare