Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
staff interviews, review of the facility policy, and record review, the facility failed to ensure pharmacy
recommendations were followed up and implemented timely. This affected three (Residents #14, #20 and
#25) of five residents reviewed for unnecessary medications. The facility census was 31.
Findings include
1. Review of the medical record for Resident #20 revealed an admission date of 12/20/21. Diagnoses
included gastroesophageal reflux disease (GERD). Review of the Minimum Data Set (MDS) assessment
dated [DATE] revealed Resident #20 had moderate cognitive impairment.
Review of the physician orders for Famotidine (treats GERD) revealed from 01/14/222 to 04/28/23,
Famotidine was to be administered at 40 milligrams (mg) tablet daily. On 04/28/23, the order for Famotidine
was changed to 20 mg tablet daily.
Review of the monthly pharmacy recommendation dated 03/21/22 revealed it was reviewed by the
physician on 03/24/22. The recommendation was for Famotidine 40 mg once daily to be decreased to 20
mg daily. The physician marked agree. However, the physician order was not completed until 04/28/23.
Review of the monthly pharmacy recommendation dated 04/27/23 revealed it was reviewed by the
physician on 04/28/23. The recommendation was for Famotidine 40 mg daily to be decreased to 20 mg
daily. The physician marked agree.
Interview on 05/03/23 at 2:10 P.M. with the Director of Nursing (DON) confirmed the decrease in Famotidine
was not done timely after the pharmacy recommendation was made and the physician agreed to pharmacy
recommendation.
2. Review of the medical record for Resident #25 revealed an admission date of 08/23/21. Diagnoses
included polyneuropathy, osteoarthritis and pain in the joints. Review of the annual Minimum Data Set
(MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact.
Review of the monthly pharmacy recommendation dated 12/29/22 revealed it was reviewed by the
physician on 12/30/22. The recommendation was for a complete blood count (CBC) at least every 12
months and a serum creatinine lab every six months due to Eliquis medication. The physician marked
agree.
Review of the physician orders dated 12/29/22 to 05/03/23 revealed there was no physician order for a
serum creatinine lab to be drawn every six months or a CBC draw for every 12 months.
(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 6
Event ID:
366246
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
366246
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cherith Care Center at Willow Brook
100 Willow Brook Way, South
Delaware, OH 43015
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)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the laboratory value results for Resident #25 dated 05/31/22 revealed a serum Creatinine were
completed on 05/31/22. From 06/01/22 to 05/03/23, there was no serum Creatinine or CBC completed
during this time.
Interview on 05/03/23 at 4:10 P.M. with the Director of Nursing (DON) confirmed the last creatine lab was
done in 05/2022 and there was no CBC draw from 06/01/22 to 05/02/23. The DON confirmed there was no
physician order for this to be completed.
3. Review of the medical record for the Resident #14 revealed an admission date of 11/18/21. Diagnoses
included gastroesophageal reflux disease (GERD). Review of the annual Minimum Data Set (MDS)
assessment dated [DATE] revealed Resident #14 was cognitively intact.
Review of the monthly pharmacy recommendation dated 01/31/23 revealed it was reviewed by the
physician on 02/03/23. The recommendation was for Protonix to be reduced from 40 mg to 20 mg. The
physician marked agree.
Review of Resident #14's physician orders dated from 0/1/31/21 to 05/02/23 revealed an order for Protonix
(treats GERD) 40 milligrams (mg) to administer one tablet daily. There was no physician order to administer
Protonix 20 mg daily during this time period.
Interview on 05/03/23 at 4:10 P.M. with the Director of Nursing (DON) revealed no evidence of the Protonix
medication orders being changed or followed up on after the pharmacy recommendation. DON confirmed
the pharmacy recommendations were provided to the physician and the physician signs off timely and two
nurses should be updating the orders. The DON confirmed the facility had no system in place to ensure the
recommendations were followed up on after physician signature.
Interview on 05/04/23 at 9:47 A.M. with Medical Director (MD) #606 revealed he receives the pharmacy
recommendation and completes within about a week. MD confirmed the signed forms were then provided
to the DON for follow up. MD revealed the facility had no process in place to verify orders were
implemented in the medical record orders.
Review of the facility policy titled Pharmacy Services, dated 2023, revealed the policy stated a pharmacist
would be involved with eliminating errors and addressing medication concerns.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366246
If continuation sheet
Page 2 of 6
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
366246
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cherith Care Center at Willow Brook
100 Willow Brook Way, South
Delaware, OH 43015
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, and review of the facility policy, the facility failed to have a
medication error rate less than five percent. There were two medication errors out of 26 opportunities
resulting an a 7.69 percent (%) medication error rate. This affected two (Resident #14 and #19) of four
residents observed for medication administration. The facility census was 31.
Residents Affected - Few
Findings include:
1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included supraventricular tachycardia, age related osteoporosis, and dementia with severe
agitation.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident
#19 was severely cognitively impaired, had no delusions, hallucinations, or behaviors documented.
Review of Resident #19's physician orders revealed an order for Oyster Shell Calcium (supplement) 500
milligram (mg) - five micrograms (mcg) with Vitamin D twice daily.
Observation of medications delivered to Resident #19 from Licensed Practical Nurse (LPN) #603 on
05/02/23 at 8:15 A.M. revealed the following medications were administered to Resident #19 orally: Eliquis
(anticoagulant) five mg, Oyster Shell Calcium 500 mg to five mcg, Seroquel (antipsychotic) 25 mg,
Seroquel (antipsychotic) 50 mg, Zoloft (antidepressant)100 mg, and Tylenol (antipyretic) 325 mg two
tablets.
Observation and interview with LPN #603 on 05/02/23 at 12:53 P.M. confirmed the Oyster Shell Calcium
500 mg-five mcg was in the medication cart and was administered to Resident #19. LPN #603 verified she
administered Oyster Shell Calcium 500 mg - five mcg to Resident #19 and the medication had no Vitamin D
included in the medication.
2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included depression, atrial fibrillation, and diabetes mellitus (DM).
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was
cognitively intact, had a diagnosis of DM, and received insulin.
Observation of Resident #14 receiving medications from Licensed Practical Nurse (LPN) #601 on 05/02/23
at 11:48 A.M. revealed the resident received Novolog insulin five units via a delivery pen, and Oxybutynin
(anticholinergic) five milligrams (mg) orally. LPN #601 was observed to dial the Novolog pen to five units
and administer the medication to Resident #14.
Interview with LPN #601 on 05/02/23 at 11:53 A.M. confirmed she had primed the Novolog insulin pen with
one unit of insulin prior to dialing the five units required for the dose that was administered to the resident.
Review of the policy titled Insulin Pen Administration, dated 2022, revealed the facility is to use insulin pens
in order to improve the accuracy of insulin dosing, provide increased resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366246
If continuation sheet
Page 3 of 6
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
366246
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cherith Care Center at Willow Brook
100 Willow Brook Way, South
Delaware, OH 43015
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)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon
discharge.
The policy explanation and compliance guidelines included insulin pens will be primed prior to each use to
avoid collection of air in the insulin reservoir. The instructions state to prime the insulin pen; Dial two units
by turning the dose selector clockwise; With the needle pointing up, push the plunger, and watch to see that
at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears;
Set the insulin dose; Turn the dose selector to ordered dose. A click will be heard for each unit dialed. If an
incorrect dose has been set, dial the dose selector forward or backward until the correct number of units
has been set; then check dose a second time.
Review of the undated policy titled Medication Administration revealed medications are administered by
licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician
and in accordance with professional standards of practice, in a manner to prevent contamination or
infection. The guidelines included to review Medication Administration Record (MAR) to identify medication
to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name,
medication name, form, dose, route, and time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366246
If continuation sheet
Page 4 of 6
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
366246
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cherith Care Center at Willow Brook
100 Willow Brook Way, South
Delaware, OH 43015
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interview, and review of the facility policy, the facility failed to administer
Residents Affected - Few
insulin correctly to a resident, resulting in a resulting in a significant medication error. This affected one
(Resident #14) of four residents observed for medication administration. The facility census was 31.
Findings include:
Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included depression, atrial fibrillation, and diabetes mellitus (DM).
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was
cognitively intact, had a diagnosis of DM, and received insulin.
Observation of Resident #14 receiving medications from Licensed Practical Nurse (LPN) #601 on 05/02/23
at 11:48 A.M. revealed the resident received Novolog insulin five units via a delivery pen, and Oxybutynin
(anticholinergic) five milligrams (mg) orally. LPN #601 was observed to dial the Novolog pen to five units
and administer the medication to Resident #14.
Interview with LPN #601 on 05/02/23 at 11:53 A.M. confirmed she had primed the Novolog insulin pen with
one unit of insulin prior to dialing the five units required for the dose that was administered to the resident.
Review of the policy titled Insulin Pen Administration, dated 2022, revealed the facility is to use insulin pens
in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a
teaching aid to prepare residents for self-administration of insulin therapy upon discharge.
The policy explanation and compliance guidelines included insulin pens will be primed prior to each use to
avoid collection of air in the insulin reservoir. The instructions state to prime the insulin pen; Dial two units
by turning the dose selector clockwise; With the needle pointing up, push the plunger, and watch to see that
at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears;
Set the insulin dose; Turn the dose selector to ordered dose. A click will be heard for each unit dialed. If an
incorrect dose has been set, dial the dose selector forward or backward until the correct number of units
has been set; then check dose a second time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366246
If continuation sheet
Page 5 of 6
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
366246
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cherith Care Center at Willow Brook
100 Willow Brook Way, South
Delaware, OH 43015
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interview and review of the facility policy, the facility failed to ensure safe and
sanitary food storage in the refrigerator and freezer in the main kitchen area. This had the potential to affect
all 31 residents residing in the facility who received food from the kitchen.
Findings include:
Observations on 05/01/23 at 9:56 A.M. of the kitchen revealed a cup of creamer or milk left uncovered and
had spilled on a tray in the refrigerator; a pre-made plate of sausage with peppers and onions was left
undated in the refrigerator; coconut shrimp was in an individually sized portioned zip lock bag and was left
open to air in the freezer; a pack of veggie burgers were left open to air in the freezer; a bag of rice was on
top of a container with rice bags inside of it. The individual bag was undated; a metal container of hot dogs
were left uncovered and open to air in the freezer; a bag of fries was undated and had a hole with food
coming out of the hole in the freezer; two pies were left on a rack in the walkway of the kitchen undated and
uncovered open to air; a tray of cookies were left on a rack in the hallway of the kitchen undated and
uncovered open to air; and a cart of desserts were in left in a cart on shelves and were left uncovered and
open to air.
Interview on 05/01/23 at 10:15 A.M. with Corporate Coordinator of Culinary Services (CCCS) #605
confirmed the findings and revealed the milk was just left and staff should have removed it and revealed the
display plate was not planned to be eaten but was a display for residents in independent living for the meal.
CCCS #605 revealed it was unknown if the bag of rice was extra and did not fit in the container below it or it
was from the previous container. CCCS #605 confirmed the pies and cookies were not covered and
revealed they were recently made and would be cut and put on plates and placed in the cart until time for
service.
Review of the facility policy titled Food Safety Requirements, dated 2023, revealed the facility policy stated
food would be stored in accordance with professional standards for food safety. Food should be stored in a
manner that prevents deterioration or contamination of the food. Refrigerator and freezer areas shall
maintain safe storage including labeling, dating and monitoring food so it was used by the use-by date and
keeping food covered or in tight containers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366246
If continuation sheet
Page 6 of 6
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the May 4, 2023 survey of CHERITH CARE CENTER AT WILLOW BROOK?
This was a inspection survey of CHERITH CARE CENTER AT WILLOW BROOK on May 4, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CHERITH CARE CENTER AT WILLOW BROOK on May 4, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.