Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
Observation on 01/15/20 at 9:12 A.M. revealed a can of air freshener and deodorizer had been left
unattended on the hand rail near the Social Service Office. The can read danger: extremely flammable
aerosol. Causes serious eye irritation. May cause drowsiness or dizziness.
Interview on 01/15/20 at 9:15 A.M. with the Housekeeping Supervisor #316 provided verification the air
freshener and deodorizer can had been left, unattended, on the hand rail. The facility confirmed the
unlocked and unsecured air freshener and deodorizer had the potential to affect 77 (#2, #3, #4, #5, #6, #7,
#8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35,
#38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70,
#72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98,
#100, #102, #103, #104, #105, #106, #258 and #259) residents who cognitively impaired and
independently mobile.
Based on medical record review, observations and staff interview, the facility failed to ensure fall
interventions were utilized as identified in the plan of care. This affected one (#57) of one resident reviewed
for falls. Additionally, the facility failed to ensure chemicals were stored in a safe manner. This had the
potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #18, #19, #20, #21, #22,
#25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46, #48, #53, #54, #55, #56, #57, #58,
#59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81, #82, #83, #85, #86, #87, #88, #89,
#91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105, #106, #258 and #259) residents the
facility identified as cognitively impaired and independently mobile. The census was 107.
Findings include:
1. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on
[DATE]. Diagnoses include Parkinson's disease, dementia, psychosis, anxiety, mood disorder, dysphonia,
hypokalemia, hypertension, heart disease, history of falls, speech disturbances, and muscle weakness.
Review of a care plan revision date 09/06/19, revealed Resident #57 was a high risk for falls related to a
history of multiple falls at home prior to admission, decreased mobility, generalized weakness, episodes of
confusion, incontinence and complaints of pain at times. The care plan revealed the resident was impulsive
a times and would self transfer/ambulate without calling for assist. The resident had poor safety awareness,
a history of crawling out of bed, and removing shoes. Interventions included dycem above and below
cushion in wheelchair and hipsters to be worn daily.
(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 8
Event ID:
365341
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of a progress note dated 12/11/19 at 10:50 P.M. revealed Resident #57 was observed on the living
room floor, laying on his/her right lateral side with knees slightly bent and head resting on the floor. A head
to to assessment was completed with no injuries observed. A neurological assessment was documented as
within normal limits for the resident. Continued review of the progress note revealed the resident was not
wearing hipsters and there was no dycem on top of Resident #57's wheel chair cushion.
Residents Affected - Some
Interview on 01/16/20 at 9:21 A.M. with Registered Nurse (RN) #177 revealed Resident #57 had an
unwitnessed fall from his/her wheel chair on 12/11/19 at approximately 10:50 P.M. RN #177 verified
Resident #57 was not wearing hipsters and there was no dycem on top of the resident wheel chair cushion
as identified in the residents plan of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 2 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, staff interview, and policy review, the facility failed to ensure medication was secured
in the medication cart. This had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13,
#14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46,
#48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81,
#82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105,
#106, #258 and #259) residents the facility identified as cognitively impaired and independently mobile. The
census was 107.
Findings include:
Observation on 01/15/20 at 7:30 A.M. revealed Registered Nurse (RN) #101 was in a communal area,
located next to a kitchette and a dining room, preparing medication for Resident #33. Observation of the
immediate area revealed resident's were in the dining room eating and being served breakfast by dietary
staff and state tested nurse aides (STNA's). RN #101 placed Resident #33's medications in a medication
cup, walked away from the medication cart, down a hallway and out of sight of the medication cart to
deliver/administer the medication to Resident #33 in the resident's room. The observation revealed RN
#101 did not secure or lock the medication cart prior to leaving the cart unattended. Further observation
revealed RN #101 returned to the medication cart to continue medication administration on 01/15/20 at
7:37 A.M.
Interview on 01/15/20 at 7:37 A.M. with RN #101 verified the failure to lock the medication cart when he/she
left the cart unattended to administer medications to Resident #33. RN #101 confirmed the medication cart
contained prescription and over-the-counter medications. The facility confirmed the unlocked and
unsecured medication cart had the potential to affect 77 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13,
#14, #16, #18, #19, #20, #21, #22, #25, #26, #28, #30, #31, #32, #34, #35, #38, #39, #43, #44, #45, #46,
#48, #53, #54, #55, #56, #57, #58, #59, #61, #63, #65, #66, #67, #69, #70, #72, #75, #76, #77, #78, #81,
#82, #83, #85, #86, #87, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #100, #102, #103, #104, #105,
#106, #258 and #259) residents who were cognitively impaired and independently mobile.
Review of a facility policy titled, Medication Storage in the Facility dated 09/04/19, revealed medications
were to be stored safely, securely, and properly following the manufacturer's recommendations. The
medication supply was to be accessible only to licensed nursing personnel, pharmacy personnel, or staff
members lawfully authorized to administer medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 3 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, staff and resident interview and policy review, the facility failed to provide a resident
with requested dental services. This affected one (#82) of one resident reviewed for dental services. The
facility identified 58 residents who receive dental services from the facility dental provider. The facility
census was 107.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #82 revealed the resident was admitted to the facility on [DATE]
and re-admitted on [DATE]. Diagnoses include atrial fibrillation (irregular heart beat), heart failure, diabetes
mellitus type II, obstructive sleep apnea, valvular heart disease, morbid obesity, anemia, polyarthritis and
acute kidney failure.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no
cognitive deficits or abnormal behaviors. Extensive assistance was required for bed mobility, transfers,
walking, dressing, toileting and personal hygiene. Supervision was required for locomotion and eating. The
resident was on a routine scheduled pain medication regime and also received as needed pain medications
and non-medication intervention for pain for frequent pain, rated as a seven on a zero to 10 scale. Resident
#82 has a significant weight gain not prescribed by the physician. No dental issues were identified. Opioids
were received seven days of the assessment period. The assessment further revealed the resident did not
receive therapy services or restorative nursing programs during the assessment period.
Review of the plan of care for Resident #82 dated 09/23/19 revealed the resident had dental health
problems related to a broken tooth from biting down onto a hard item. Interventions included coordinating
arrangements for dental care, including transportation if needed.
Review of an authorization for professional services dated 09/19/19 included the use of dental services
provided by Mobile Dental Group #1 and was signed by Resident #82.
Review of an undated Dental exam and hygiene authorization form provided by the Director of Nursing
(DON) revealed the form had Resident #82's name on it and it was from the dental service office. The form
revealed different levels of treatment that could be provided as well as the cost of the service that would
need to be paid prior to the service being rendered. The form further revealed for medicaid residents, they
were to call the office and notify the dental office to change their financial status. Several of the services
listed were to be covered by Medicaid.
Review of a notification note dated 11/08/19 revealed the facility shared an authorization form with Resident
#82 and had the resident sign the form on 11/20/19 for a dental exam and hygiene.
Review of progress notes dated 10/17/19 revealed Resident #82 was approached due to her request to see
the dentist. It further revealed the resident would like to see in-house dentist A request for orders for
ancillary services was to be put in at this time.
Review of physician progress notes dated 01/03/20 revealed the resident voiced the need to see a dentist.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 4 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 0791
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Further review of the medical record for Resident #82 provided no documentation the resident had been
provided dental services.
Interview with Resident #82 on 01/13/20 at 10:42 A.M. revealed she had a broken bottom right molar tooth
as well as a cavity that needed to be fixed. Resident #82 stated she did not have constant pain due to this,
but it did hurt frequently as she ate. She stated she had asked to see a dentist on seven occasions since
she had been admitted to the nursing facility. Resident #82 further stated she was told the dentist came
every three months and she asked if she could have her name added to the waiting list. Resident #82
further stated when she asked the nurses the last time, she was informed the dentist had been to the
facility in November and how she would have to wait until he came back in February.
Interview with the DON 01/16/20 at 3:00 P.M. revealed the facility had a binder of residents who were
supposed to see the dentist. The DON stated the dentist did come every three months and could also have
emergency appointments if needed. The DON stated Resident #82 was on the list of residents to be seen
by the dentist at sometime in the next 10 days. The DON stated she had received a letter from the dentist to
give to the resident for payment. The DON stated those forms were for private pay residents. She stated
when the dentist was at the facility in 11/20/19, Resident #82 had been given a form but had not provided
payment. The DON further verified Resident #82 received Medicaid services and should have not been
provided a form for payment. She further verified the facility should have notified the dental group of the
resident's financial status when she signed the authorization in 09/2019. She stated the facility should have
realized when the dentist was here in 11/20/19, that the resident was covered by Medicaid and did not have
to pay for dental services. The DON further verified the facility still had not notified the dental group when
they received the same form for the resident. The DON stated the form she had been given by the dental
group to be seen in 01/2020 was also for the resident's need for payment and fee that was required. The
DON verified she should have called the dental group at the time she received the notice to be sure it was
fixed, but she had not. The DON further stated usually the second shift charge nurse was responsible for
adding residents' name to the ancillary service list. She stated they had been unable to keep that position
filled and she was not responsible for this duty.
Further interview with the DON on 01/16/20 at 4:00 P.M. verified although she was not aware of a previous
request from Resident #82 to see a dentist, she should have noticed the discrepancy in financial status
when she received a 10 day notice of which residents were to be seen by the dentist. She verified she
should have taken time to realize the discrepancy and to take care of the discrepancy before the dentist
arrived. The DON further verified the plan of care for Resident #82 dated 09/2019 shortly after the
resident's admission, revealed the need for the resident to see a dentist due to a broken tooth and it had
not been done by the facility.
Review of facility policy Dental Services dated 05/09/17 revealed the facility was to assist the residents in
obtaining routine and 24 hour emergency dental care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 5 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff and resident interview, review of a food temperature form and policy review, the
facility failed to ensure the food was palatable and at the correct holding temperature. This had the potential
to all residents residing in the facility except two (#20 and #47) residents who were ordered to receive
nothing by mouth. The facility census was 107.
Residents Affected - Some
Findings include:
Observation of Oakbridge Section D with Dietary Staff #552 on 01/14/19 at 5:11 P.M. revealed the staff
member plated food from the hot holding area onto a test tray. The temperature of the test tray was
immediately checked which revealed the chicken temped at 106 degree Fahrenheit (F), carrots temped at
119 degrees F and mashed potatoes temped at 127 degrees F. Dietary Staff #552 and the surveyor tasted
the food which did not taste warm, chicken was tough and cold.
Interview with Resident #82 on 01/14/20 at 5:30 P.M. revealed her chicken for supper meal was cold and
dry.
Interview with Food Services Supervisor #507 on 01/14/20 at 5:45 P.M. revealed the only temperatures
taken of the food prior to service in completed in the kitchen. The food is taken from the main kitchen out to
the neighborhoods via hot boxes and placed in the warmers. The facility confirmed this had the potential to
affect 105 out of 107 residents receive their meals from the kitchen and that two (#20 and #47) residents
were ordered to receive nothing by mouth.
Observations of temperatures on 01/15/19 at 9:30 A.M. taken in the kitchen for lunch revealed the staff took
temperatures at 9:30 A.M. then placed in hot box then not taken to the neighborhoods until 11:30 A.M.
Review of the facility's Daily Food Temperature Form revealed there were no temperatures taken at any of
the neighborhoods before or during food service.
Review of the facility's undated policy Food Safety Code Regulations revealed handling hot and cold
holding cooking or cooling foods shall be maintained at 135 degrees F or above.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 6 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff and resident interview, review of a local health department inspection report,
review of a facility food temperature form and policy review, the facility failed to ensure staff practiced
proper hand hygiene when serving food to residents. Additionally, the facility failed to maintain safe foods
temperatures for food items held in the neighborhood kitchens. This had the potential to affect all residents
except for two (#20 and #47) who were ordered to receive nothing by mouth. The census was 107.
Findings include:
1. Observation on 01/13/20 at 11:25 A.M. revealed Dietary Staff #500 entered Resident #28's room with a
lunch tray and moved personal items from the over bed table. Dietary Staff #500 placed the tray onto the
over bed table and spoke with resident about her shoes. Dietary Staff #500 proceeded to touch the tops of
Resident #28's shoe. Dietary Aide #500 exited the room and proceeded to enter the kitchenette in Maple
Run and began to touch dishes.
Interview on 01/13/20 at 11:30 A.M. with Dietary Staff #500 provided verification she had not changed her
gloves or washed her hands, or used hand sanitizer, after touching numerous personal items and shoes of
Resident #28 prior to starting to touch other dishes to serve other residents.
2. Observation on Oakbridge section D on 01/14/20 at 4:59 P.M. revealed Dietary Staff #552 had placed
gloves on and opened the microwave, opened the refrigerator, then opened the freezer and took out a bag
of frozen hot dogs. Dietary Staff #552 opened up the bag and reached in with her contaminated glove and
put a hotdog on a plate. Dietary Staff #552 verified she should have changed her contaminated gloves
before touching the hotdog.
3. Observation of on 01/14/19 at 5:07 P.M. of Dietary Staff #510 on Oakbridge Section D revealed she had
gloves on then she touched the countertop, the cabinet door and moved the hotbox looking for the
residents personal bread. Dietary Staff #510 found the bread under the counter and with the contaminated
gloves opened up the bag of bread and started to get out a slice of bread. Dietary Staff #510 verified she
should have changed her gloves due to being contaminated before touching any food.
4. Observation of Oakbridge Section D with Dietary Staff #552 on 01/14/19 at 5:11 P.M. revealed the staff
member plated food from the hot holding area onto a test tray. The temperature of the test tray was
immediately checked which revealed the chicken temped at 106 degree Fahrenheit (F), carrots temped at
119 degrees F and mashed potatoes temped at 127 degrees F. Dietary Staff #552 and the surveyor tasted
the food which did not taste warm, chicken was tough and cold.
Interview with Resident #82 on 01/14/20 at 5:30 P.M. revealed her chicken for supper meal was cold and
dry.
Interview with Food Services Supervisor #507 on 01/14/20 at 5:45 P.M. revealed the only temperatures
taken of the food prior to service in completed in the kitchen. The food is taken from the main kitchen out to
the neighborhoods via hot boxes and placed in the warmers. Food Services Supervisor #507 confirmed
food temperatures are not checked when the food is being held on the hot holding areas to ensure the food
is at an appropriate and safe level. The facility confirmed there have been no food borne illness; however,
further confirmed this had the potential to affect 105 out of 107
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 7 of 8
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
365341
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/16/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Briarwood Village
100 Don Desch Drive
Coldwater, OH 45828
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 who receive their meals from the kitchen and that two (#20 and #47) residents were ordered to
receive nothing by mouth.
Observations of temperatures on 01/15/19 at 9:30 A.M. taken in the kitchen for lunch revealed the staff took
temperatures at 9:30 A.M. then placed in hot box then not taken to the neighborhoods until 11:30 A.M.
Residents Affected - Some
Review of the local health department inspection reported dated 11/14/19 revealed the facility received two
violations from the local health department. The report documented violations regarding Time/Temperature
Control for Safety (TCS) foods not being held at the proper temperature. One instance was found in one of
the satellite kitchens where the hot food items were not at 135 degrees F and the food item had to be
discarded. Additionally, TCS foods not being cold held at the proper temperature in the following
refrigeration units: main kitchen 2-door reach in (44 degrees F); Oak A refrigerator (47 degrees F); Cedar
(46-50 degrees F).
Review of the facility's Daily Food Temperature Form revealed there were no temperatures taken at any of
the neighborhoods before or during food service to ensure foods were maintained at a safe temperature.
Review of the facility's undated policy Food Safety Code Regulations revealed handling hot and cold
holding cooking or cooling foods shall be maintained at 135 degrees F or above.
Review of the facility policy titled Hand Hygiene Procedures dated 03/09, revealed alcohol hand sanitizer
should be used before entering or exiting a resident room and after contact with inanimate objects.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365341
If continuation sheet
Page 8 of 8
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Back to topCitations
5 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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F761 - Labeling of Drugs and Biologicals
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.
F791 - Dental Services
Provide or obtain dental services for each resident.
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 January 16, 2020 survey of BRIARWOOD VILLAGE?
This was a inspection survey of BRIARWOOD VILLAGE on January 16, 2020. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIARWOOD VILLAGE on January 16, 2020?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.