Cycle 1
Health 2025-03-06 · Fire 2025-03-06
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Greenville, OH
Brethren Retirement Community
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
750 Chestnut Street, Greenville, OH
(937) 547-8000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.49
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.76
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,190
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Baseline 17.62% · Performance 20.32% · Measure score 2.41 · Achievement 2.41 · Improvement 0
Healthcare-associated infections
7.13
Baseline 6.43% · Performance 5.71% · Measure score 7.13 · Achievement 7.13 · Improvement 4.55
Total nurse turnover
5.18
Baseline 43.21% · Performance 42.50% · Measure score 5.18 · Achievement 5.18 · Improvement 0
Adjusted total nurse staffing
3.51
Baseline 4.02 hours · Performance 4.08 hours · Measure score 3.51 · Achievement 3.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.81% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 8.27% · Lower 95% interval 6.96% |
| Discharge to community | 65.4% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 122 · Observed rate 62.3% · Lower 95% interval 58.26% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 66.13% |
95.27%
29.1 pts worse
|
Numerator 41 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 63.83% |
53.69%
10.1 pts better
|
Numerator 30 · Denominator 47 |
| Discharge mobility score | 46.81% |
50.94%
4.1 pts worse
|
Numerator 22 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 62 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 1.43% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 16.43% |
8.2%
8.2 pts better
|
Numerator 35 · Denominator 213 |
| Staff flu vaccination coverage | 55.44% |
42%
13.4 pts better
|
Numerator 214 · Denominator 386 |
| Discharge function score | 55.32% |
56.45%
1.1 pts worse
|
Numerator 26 · Denominator 47 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 18.92% |
25.2%
6.3 pts worse
|
Numerator 7 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
1.8
1.7 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
92.4%
4.7 pts worse
|
93.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.5% · Q3 79.7% · Q4 75.0% · 4Q avg 87.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
94.5%
3.9 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.9% |
3.3%
5.6 pts worse
|
3.3%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.5% · Q3 8.5% · Q4 10.0% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
26.1%
23.8 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 1.9% · Q4 3.6% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.2%
0.7 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.3% · Q3 4.8% · Q4 5.9% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
25.4%
5.4 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.6% · Q3 20.9% · Q4 21.6% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
11.5%
1.8 pts worse
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 16.1% · Q3 5.7% · Q4 9.8% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
7.7%
17 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 34.8% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
6.2%
15.2 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 28.6% · Q3 21.1% · Q4 17.0% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.5%
0.4 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
21.7%
9.8 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 35.7% · Q3 29.9% · Q4 25.6% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
3.7%
3.3 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.8% |
78.1%
0.3 pts worse
|
81.7%
3.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 74.2% · Q3 70.5% · Q4 77.0% · 4Q avg 77.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.8% |
12.5%
10.3 pts worse
|
12.0%
10.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 22.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.4% |
75.6%
11.2 pts worse
|
79.7%
15.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
25.1%
2.6 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 22.7% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-13 · Fire 2022-06-13
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-14
F · Potential for more than minimal harm
2025-03-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-14
E · Potential for more than minimal harm
2025-03-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-14
F · Potential for more than minimal harm
2022-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-29
E · Potential for more than minimal harm
2019-05-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-06-26
E · Potential for more than minimal harm
2019-05-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-06-26
E · Potential for more than minimal harm
2019-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-19
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-11-08
D · Potential for more than minimal harm
2025-04-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-20
G · Actual harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-24
D · Potential for more than minimal harm
2024-06-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-30
D · Potential for more than minimal harm
2023-06-30
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-17
F · Potential for more than minimal harm
2022-06-13
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-29
G · Actual harm
2019-05-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-16
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-16
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-06-26
D · Potential for more than minimal harm
2019-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-26
Penalties and ownership
What sits behind the stars
$0
2025-03-06
Payment Denial
Payment Denial · denial start 2025-04-02 · 22 days
22 day denial
Ownership
Allread, Kara
W-2 Managing Employee · Individual
Arnold, Matthew
Corporate Director · Individual
Eubank, Carl
W-2 Managing Employee · Individual
Fifth Third Bank, National Association
5% Or Greater Mortgage Interest · Organization
Gasper, Lisa
W-2 Managing Employee · Individual
Hill, Holly
W-2 Managing Employee · Individual
Jaros, Frank
W-2 Managing Employee · Individual
Keen, Jami
W-2 Managing Employee · Individual
Keller, John
Corporate Director · Individual
Kepler, David
Corporate Director · Individual
Neff, Pamela
W-2 Managing Employee · Individual
Overfield, Melody
W-2 Managing Employee · Individual
Randolph, Michael
W-2 Managing Employee · Individual
Riesser, Lawrence
Corporate Director · Individual
Warner, John
Corporate Officer · Individual
Warner, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Ayden Healthcare Of Greenville
Greenville, OH
1-star overall rating with 2-star inspections with $15,593 in total fines with 18 recent health deficiencies
#2
Rest Haven Nursing Home Inc
Greenville, OH
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Village Green Rehabilitation And Healthcare Center
Greenville, OH
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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