Englewood, OH

Grace Brethren Village

3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1010 Taywood Road, Englewood, OH

(937) 836-4011

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2003-04-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,079

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.11

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.71

Baseline 22.90% · Performance 21.01% · Measure score 2.71 · Achievement 0.90 · Improvement 2.71

Healthcare-associated infections

Baseline 6.93% · Performance 8.13% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.31

Baseline 45.45% · Performance 58.33% · Measure score 1.31 · Achievement 1.31 · Improvement 0

Adjusted total nurse staffing

3.22

Baseline 4.73 hours · Performance 4 hours · Measure score 3.22 · Achievement 3.22 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.19%	10.72% 1.5 pts better	No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 5.6%
Discharge to community	56.44%	50.57% 5.9 pts better	No Different than the National Rate · Eligible stays 48 · Observed rate 50% · Lower 95% interval 39.33%
Medicare spending per beneficiary	1.1	1.02 0.1 pts worse
Drug regimen review with follow-up	45.83%	95.27% 49.4 pts worse	Numerator 11 · Denominator 24
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 24
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	4.17%	2.29% 1.9 pts worse	Numerator 1 · Denominator 24 · Adjusted rate 3.67%
Healthcare-associated infections requiring hospitalization	8.13%	7.12% 1 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.52%
Staff COVID-19 vaccination coverage	54.55%	8.2% 46.3 pts better	Numerator 30 · Denominator 55
Staff flu vaccination coverage	18.09%	42% 23.9 pts worse	Numerator 17 · Denominator 94
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	85.7%	92.4% 6.7 pts worse	93.4% 7.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 71.9% · Q2 85.3% · Q3 93.5% · Q4 93.1% · 4Q avg 85.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.2%	94.5% 2.7 pts better	95.5% 1.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of long-stay residents experiencing one or more falls with major injury	8.7%	3.3% 5.4 pts worse	3.3% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 11.8% · Q3 9.7% · Q4 6.9% · 4Q avg 8.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.9%	26.1% 24.2 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight	8.9%	6.2% 2.7 pts worse	5.4% 3.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.5% · Q3 8.0% · Q4 8.3% · 4Q avg 8.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.8%	25.4% 4.6 pts better	19.6% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 26.9% · Q3 16.0% · Q4 12.5% · 4Q avg 20.8%
Percentage of long-stay residents who received an antipsychotic medication	2.3%	11.5% 9.2 pts better	16.7% 14.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · 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	26.5%	7.7% 18.8 pts worse	16.3% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.8%	6.2% 7.6 pts worse	14.9% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 25.0% · Q3 13.0% · Q4 0.0% · 4Q avg 13.8% · 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	0.0%	0.5% 0.5 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	35.1%	21.7% 13.4 pts worse	19.8% 15.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 36.5% · Q3 35.8% · Q4 40.8% · 4Q avg 35.1%
Percentage of long-stay residents with pressure ulcers	2.9%	3.7% 0.8 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 6.9% · Q4 2.8% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	67.9%	78.1% 10.2 pts worse	81.7% 13.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 55.0% · Q2 76.8% · Q3 68.3% · Q4 71.9% · 4Q avg 67.9%
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.2% 0.4 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	77.0%	75.6% 1.4 pts better	79.7% 2.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 77.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-30 · Fire 2025-01-30

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2022-03-31 · Fire 2022-03-31

9 health deficiencies

Top issue: Resident Rights (3 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2020-02-27 · Fire 2020-02-27

12 health deficiencies

Top issue: Infection Control (3 deficiencies)

4 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-30

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 2025-03-28

E · Potential for more than minimal harm 2025-01-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-28

E · Potential for more than minimal harm 2025-01-30

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-28

F · Potential for more than minimal harm 2022-03-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-05-06

F · Potential for more than minimal harm 2022-03-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-05-06

F · Potential for more than minimal harm 2022-03-31

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-05-06

F · Potential for more than minimal harm 2022-03-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-05-06

F · Potential for more than minimal harm 2022-03-31

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 2022-05-06

F · Potential for more than minimal harm 2022-03-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-05-06

E · Potential for more than minimal harm 2022-03-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-05-06

F · Potential for more than minimal harm 2020-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-04-15

F · Potential for more than minimal harm 2020-02-27

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2020-04-15

F · Potential for more than minimal harm 2020-02-27

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2020-04-15

C · Minimal harm 2020-02-27

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2020-04-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-27

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-09-10

D · Potential for more than minimal harm 2025-04-09

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-04-24

D · Potential for more than minimal harm 2025-04-09

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-04-24

G · Actual harm 2025-03-13

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 2025-03-28

E · Potential for more than minimal harm 2025-01-30

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 2025-03-28

D · Potential for more than minimal harm 2025-01-30

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 2025-03-28

D · Potential for more than minimal harm 2025-01-30

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-03-28

D · Potential for more than minimal harm 2025-01-30

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 2025-03-28

D · Potential for more than minimal harm 2025-01-30

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2025-03-28

F · Potential for more than minimal harm 2023-12-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-12-08

D · Potential for more than minimal harm 2023-08-01

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-08-28

D · Potential for more than minimal harm 2023-08-01

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 2023-08-28

F · Potential for more than minimal harm 2022-03-31

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 2022-05-06

D · Potential for more than minimal harm 2022-03-31

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2022-05-06

D · Potential for more than minimal harm 2022-03-31

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 2022-05-06

D · Potential for more than minimal harm 2022-03-31

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 2022-05-06

D · Potential for more than minimal harm 2022-03-31

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-05-06

D · Potential for more than minimal harm 2022-03-31

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-05-06

D · Potential for more than minimal harm 2022-03-31

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 2022-05-06

D · Potential for more than minimal harm 2022-03-31

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-05-06

D · Potential for more than minimal harm 2022-03-31

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2022-05-06

F · Potential for more than minimal harm 2020-02-27

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 2020-04-15