Health inspection·April 14, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of self-reported incident (SRI), review of witness statements, review of in-service, review of employee file, review of corrective action, and review of policy, the facility failed to protect residents from neglect/physical abuse. This affected one (#1) of three residents reviewed for abuse. The facility census was 67. Findings include: Review of the medical record of Resident #1 revealed an admission date of 05/24/23. Diagnoses include Alzheimer's disease, dementia without behavioral disturbance, and symptoms and signs involving cognitive functions and awareness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively impaired and required extensive assistance with personal hygiene. Review of the facility investigation revealed a hand-written statement from the Certified Nurse Assistant (CNA) #109 with date of observation 03/15/24 (all others in investigation dated 03/15/25) with a statement I accidentally wiped a bed matt and then used the same cloth to wash a resident's face. I'm sorry won't ever happen again. I'm so upset and preoccupied by losing my friend an it's been very hard to concentrate since finding this out. Review of a hand-written statement written by Licensed Practical Nurse (LPN) #107, dated 03/17/25, with a date of incident 03/15/25 at 2:00 P.M. to 2:45 P.M., revealed Housekeeper #105 had reported to CNA #103 she had witnessed CNA #109 wipe Resident #01's face with a feces-stained wash cloth. The Director of Nursing (DON) and Administrator were called. The DON spoke with CNA #109, who immediately began to yell at Housekeeper #105 for reporting her. CNA #109 reportedly stated I have a car payment, and everyone here was after her. LPN #107 told CNA #109 to stop yelling. CNA #109 grabbed some papers and left the unit. Review of a hand-written statement written by Housekeeper #105, dated 03/15/25, with date of observation 03/15/25 estimated time 1:15 P.M. to 2:00 P.M., revealed Housekeeper #105 heard a loud plop coming from Resident #01's room. Upon entering the room Housekeeper #105 witnessed Resident #1 crying and CNA #109 said She was mad at me. Housekeeper #105 reported seeing CNA #109 wipe feces from the bed and use the same cloth to wipe Resident #1's face. (continued on next page) 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 Page 1 of 3 Event ID: 365014 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brethren Retirement Community 750 Chestnut Street Greenville, OH 45331 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)