Inspection Reports for
Briarwood Village
100 DON DESCH DRIVE, COLDWATER, OH, 45828
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
132% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 3
Date: Sep 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to respond to resident concerns, incomplete scheduled showers, and failure to follow infection control procedures for a resident positive with COVID-19.
Complaint Details
This deficiency report represents non-compliance investigated under Complaint Number 2595568.
Findings
The facility failed to respond to resident council concerns, did not provide scheduled showers to some residents, and did not follow proper infection prevention and control protocols for a COVID-19 positive resident, including lack of isolation signage and improper PPE use.
Deficiencies (3)
F 0565: The facility failed to respond to resident concerns raised in resident council meetings, affecting two residents. There was no evidence of action taken to address issues such as dietary concerns, late medication delivery, and improper bedding.
F 0677: The facility failed to provide scheduled showers to three residents, resulting in residents going long periods without bathing assistance as required.
F 0880: The facility failed to follow infection control procedures for a COVID-19 positive resident, including open door isolation, lack of signage, presence of dirty gowns and used items in hallways, and staff not adhering to PPE protocols.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Facility census: 95
Facility census: 62
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted in response to a complaint investigation regarding a fall incident involving Resident #01, who sustained serious injuries and subsequently died. The investigation focused on supervision and accident prevention in the nursing home.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2565060. The complaint was substantiated as the facility failed to provide adequate supervision and safety measures, resulting in Resident #01's fall and death.
Findings
The facility failed to provide adequate supervision to Resident #01 during activities of daily living, resulting in the resident falling from an elevated bed and sustaining fatal injuries. The investigation revealed staff left the resident unattended in an elevated bed, and the facility lacked proper assessment and documentation of bed and mattress safety. Immediate Jeopardy was identified and later removed after corrective actions and staff education were implemented.
Deficiencies (1)
F 0689: The facility failed to ensure Resident #01 was adequately supervised during care, resulting in a fall from an elevated bed causing severe head and cervical spine injuries leading to death. Staff left the resident unattended while the bed was elevated approximately three feet, contrary to facility policies and safety guidelines.
Report Facts
Licensed nurses and CNAs educated: 46
Residents reviewed for accidents and supervision: 3
Staples placed: 6
Bed elevation height: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #69 | Licensed Practical Nurse | Heard CNA yell and responded immediately to Resident #01's fall; contacted emergency services. |
| RN #83 | Registered Nurse | Assessed Resident #01 after fall and contacted emergency medical services. |
| CNA #61 | Certified Nurse Aide | Left Resident #01 unattended while retrieving wheelchair; involved in incident leading to fall. |
| CNA #89 | Certified Nurse Aide | Left Resident #01 unattended while tending to trash; attempted to catch resident during fall. |
| PA #22 | Physician Assistant | Ordered Resident #01 to be sent to emergency room after fall. |
| DON | Director of Nursing | Confirmed bed mattress issues and led staff education and corrective actions. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Apr 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to report incidents of resident-to-resident physical abuse and failure to report norovirus cases and gastrointestinal symptoms to the local health department.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00164181. The complaint involved failure to report resident-to-resident physical abuse and failure to report infectious disease outbreaks to the appropriate authorities.
Findings
The facility failed to timely report a physical altercation between residents to the Ohio Department of Health and also failed to report multiple norovirus cases and gastrointestinal symptoms affecting many residents to the local health department. The incidents involved resident-to-resident abuse and an outbreak of norovirus affecting residents and staff.
Deficiencies (2)
F 0609: The facility failed to timely report suspected resident-to-resident physical abuse to the state agency. Resident #23 struck Resident #19 and the incident was not reported to the Ohio Department of Health.
F 0880: The facility failed to report norovirus cases and multiple residents' gastrointestinal symptoms to the local health department. This had the potential to affect all 92 residents of the facility.
Report Facts
Census: 92
Residents affected by abuse: 3
Residents affected by norovirus and GI symptoms: 92
Residents with GI symptoms: 16
Residents in memory care unit: 16
Staff positive for norovirus: 2
CNA off work: 2
Inspection Report
Census: 86
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection was conducted to evaluate compliance with staffing requirements, specifically the employment of a full-time Director of Nursing.
Findings
The facility failed to employ a full-time Director of Nursing, which had the potential to affect all 86 residents. Staffing records and interviews confirmed no Director of Nursing had been scheduled or employed since 09/18/24.
Deficiencies (1)
F 0727: The facility failed to employ a Director of Nursing full time. No Director of Nursing or acting Director of Nursing had been employed since 09/18/24.
Report Facts
Residents affected: 86
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 6
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements in multiple areas including care planning, treatment, medication management, staff performance, and training.
Findings
The facility was found deficient in developing comprehensive care plans, monitoring bruises, ensuring medication safety including outdated insulin use and medication storage, conducting timely employee evaluations, and providing required nurse aide education. These deficiencies affected multiple residents and staff files.
Deficiencies (6)
F 0656: The facility failed to develop and implement a complete care plan for a resident's corrective device, specifically a walking cast, with no physician orders or skin assessments documented.
F 0684: The facility failed to monitor bruises once observed on a resident, with no documentation to determine the age or healing of bruises.
F 0730: The facility failed to ensure State Tested Nursing Assistants had 90 day and annual performance evaluations, affecting four of six employee files reviewed.
F 0760: The facility failed to ensure residents did not receive outdated insulin, administering insulin that was beyond the 28-day discard period.
F 0761: The facility failed to ensure medications were not left at the bedside, risking medication safety and security.
F 0947: The facility failed to ensure nurse aides completed 12 hours of required education annually, affecting two of three STNA files reviewed.
Report Facts
Facility census: 99
Bruise measurements: 12
Bruise measurements: 9
Bruise measurements: 6
Insulin vial date: Jul 5, 2024
Insulin discard period: 28
STNA files affected: 4
STNA files affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #321 | Licensed Practical Nurse | Verified no care plan or physician orders for resident #195's walking cast |
| RCS #602 | Regional Clinical Services | Verified no orders, care plans, or diagnoses for resident #195's walking cast and no bruise monitoring documentation for resident #59 |
| LPN #319 | Licensed Practical Nurse | Administered outdated insulin to resident #30 and left medications at bedside for resident #26 |
| Director of Nursing | Director of Nursing | Verified insulin discard policy of 28 days |
| HR #508 | Human Resources | Verified missing evaluations for STNAs #353, #374, #370, and #331 |
| Executive Director | Executive Director | Verified STNAs #353 and #389 were not compliant with education requirements |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 10
Date: Oct 25, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's compliance with regulations related to resident care, safety, and facility conditions.
Complaint Details
The deficiencies identified relate to non-compliance with allegations in Complaint Number OH00135342, including failure to reposition dependent residents and other care concerns.
Findings
The facility was found deficient in multiple areas including cleanliness of resident rooms, incomplete skin assessments, failure to update pre-admission screenings, inadequate care planning, failure to reposition dependent residents, improper pressure ulcer care, improper medication storage and labeling, failure to limit PRN psychotropic medication use, unsanitary kitchen conditions, uncovered meal trays during transport, and lack of dementia care training for newly hired nurse aides.
Deficiencies (10)
F 0584: The facility failed to maintain clean resident rooms, affecting two residents. Rooms had visible dirt, dried stool in toilets, and unclean surfaces.
F 0636: The facility failed to complete comprehensive skin assessments timely for residents, affecting one resident. A large protruding mole was not documented or addressed.
F 0644: The facility failed to update pre-admission screening and resident review assessments when residents had new diagnoses, affecting three residents.
F 0656: The facility failed to develop and implement a complete care plan addressing a resident's actual skin concern related to a protruding mole.
F 0684: The facility failed to ensure dependent residents were repositioned as ordered, affecting one resident. Staff confirmed resident was not repositioned during observed periods.
F 0686: The facility failed to accurately assess and document treatment of pressure ulcers, affecting one resident. Pressure ulcer assessments and treatment orders were incomplete or missing.
F 0758: The facility failed to limit PRN psychotropic medication use to 14 days and failed to ensure physician evaluation after 14 days, affecting two residents.
F 0761: The facility failed to ensure medications were stored at proper temperatures in refrigerators, affecting 15 residents and potentially all residents on multiple halls.
F 0812: The facility failed to maintain sanitary kitchen conditions, failed to label and date foods, discard expired foods, and failed to cover meal trays during transport, potentially affecting all residents.
F 0947: The facility failed to provide newly hired nurse aides with training on caring for residents with dementia, affecting 44 residents diagnosed with dementia.
Report Facts
Facility census: 73
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 15
Residents affected: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #245 | Registered Nurse | Verified refrigerator temperature logs and medication storage conditions |
| Assistant Director of Nursing (ADON) #276 | Assistant Director of Nursing | Verified room cleanliness issues and nurse aide training deficiencies |
| Regional Director of Clinical Services #347 | Regional Director of Clinical Services | Verified PRN psychotropic medication orders and physician evaluations |
| Director of Nursing (DON) | Director of Nursing | Verified resident repositioning, medication storage, and kitchen food service issues |
| Housekeeping Supervisor #344 | Housekeeping Supervisor | Verified cleaning schedules and resident room conditions |
| Resident Services Coordinator (RSC) #306 | Resident Services Coordinator | Verified failure to update pre-admission screening assessments |
| MDS Registered Nurse (RN) #230 | MDS Registered Nurse | Verified skin assessment documentation issues |
| Human Resources Director #248 | Human Resources Director | Verified nurse aide personnel files and training records |
| Dietary Staff #270 | Dietary Staff | Observed transporting uncovered meal trays |
| Dietary #221 | Dietary Staff | Verified meal trays should be covered during transport |
| State Tested Nurse Aide (STNA) #266 | State Tested Nurse Aide | Verified failure to reposition resident |
| State Tested Nurse Aide (STNA) #236 | State Tested Nurse Aide | Verified failure to reposition resident and lack of dementia training |
Inspection Report
Routine
Census: 107
Deficiencies: 5
Date: Jan 15, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication security, dental services, food safety, and hygiene practices in the nursing home.
Findings
The facility was found deficient in ensuring fall interventions were followed, securing chemicals and medications, providing requested dental services, maintaining food at safe temperatures, and enforcing proper hand hygiene during food service. These deficiencies had the potential to affect a large number of residents, particularly those cognitively impaired and independently mobile.
Deficiencies (5)
F0689: The facility failed to ensure chemicals were stored safely and fall interventions were followed for a high-risk resident. This affected 77 residents and one resident reviewed for falls.
F0761: Medication was not secured in the medication cart, which was left unlocked and unattended, potentially affecting 77 residents.
F0791: The facility failed to provide requested dental services to one resident despite documented need and authorization.
F0804: Food served was not palatable and was held at unsafe temperatures, potentially affecting 105 residents.
F0812: Staff failed to practice proper hand hygiene when serving food and did not maintain safe food temperatures in neighborhood kitchens, potentially affecting 105 residents.
Report Facts
Census: 107
Residents affected by chemical storage and medication cart issues: 77
Residents affected by dental service deficiency: 58
Residents affected by food safety deficiencies: 105
Food temperature readings: 106
Food temperature readings: 119
Food temperature readings: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor #316 | Verified chemical storage issue | |
| Registered Nurse (RN) #177 | Verified fall incident and failure to follow fall interventions | |
| Registered Nurse (RN) #101 | Observed leaving medication cart unsecured | |
| Director of Nursing (DON) | Provided information on dental service deficiencies and facility policies | |
| Dietary Staff #552 | Observed plating food and improper glove use | |
| Dietary Staff #500 | Observed improper hand hygiene and glove use | |
| Dietary Staff #510 | Observed improper glove use | |
| Food Services Supervisor #507 | Confirmed food temperature and hygiene deficiencies |
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