Cycle 1
Health 2025-05-28 · Fire 2025-05-28
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Delaware, OH
Cherith Care Center At Willow Brook
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
100 Willow Brook Way, South, Delaware, OH
(740) 369-0048
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing
LPN hours / resident day
0.85
Licensed practical nurse staffing
Aide hours / resident day
3.00
Nurse aide staffing
Weekend hours
4.25
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
92.4%
5.5 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
26.1%
12.6 pts better
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 12.9% |
6.2%
6.7 pts worse
|
5.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
25.4%
2 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
11.5%
2.6 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.1% |
7.7%
20.4 pts worse
|
16.3%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.3% |
21.7%
11.6 pts worse
|
19.8%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
3.7%
2.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
78.1%
17.6 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.5%
About the same
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
75.6%
22.9 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.1%
6.8 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-04 · Fire 2023-05-04
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-10-17 · Fire 2019-10-17
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-15
F · Potential for more than minimal harm
2025-05-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-15
F · Potential for more than minimal harm
2025-05-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-15
F · Potential for more than minimal harm
2023-05-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-05-04
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 2023-05-25
F · Potential for more than minimal harm
2019-10-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-12-01
E · Potential for more than minimal harm
2019-10-17
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 2019-12-01
E · Potential for more than minimal harm
2019-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-28
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 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
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 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
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 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-15
F · Potential for more than minimal harm
2023-05-04
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 2023-05-25
D · Potential for more than minimal harm
2023-05-04
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 2023-05-25
D · Potential for more than minimal harm
2023-05-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-25
D · Potential for more than minimal harm
2019-10-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-17
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 2019-12-01
Penalties and ownership
What sits behind the stars
Ownership
Barth, Phil
Corporate Director · Individual
Davis, Brandi
Corporate Director · Individual
Dulgar, Jason
Corporate Director · Individual
Irwin, Terry
Corporate Director · Individual
Johnson, Kim
Corporate Director · Individual
Johnson, William
Corporate Director · Individual
Ketron, Nicole
Operational/Managerial Control · Individual
Longo, Scott
Corporate Director · Individual
March, Judy
Corporate Director · Individual
Mckenna, Blythe
Corporate Director · Individual
Mcknight, Matthew
Operational/Managerial Control · Individual
Mcknight, Matthew
Corporate Officer · Individual
Pickens, Roger
Corporate Director · Individual
Poulson, Thomas
Operational/Managerial Control · Individual
Poulson, Thomas
Corporate Officer · Individual
Sarkel, Ed
Corporate Director · Individual
Slingluff, Dana
Corporate Director · Individual
Susenna, Karen
Corporate Director · Individual
Tidwell, Peggy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Country Club Center V, Inc
Delaware, OH
5-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Ohio Living Sarah Moore
Delaware, OH
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Delaware Court Health Care Center
Delaware, OH
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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