Health inspection·August 8, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and the review of the facility policy, the facility failed to develop and initiate a care plan in regards to a corrective device for a resident. This affected one resident (#195) of three residents reviewed for range of motion. The facility census was 99. Findings include: Record review for Resident #195 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #195 included post surgical care for digestive tract, overactive bladder, sciatica, and pulmonary hypertension. Further review of Resident #195's list of diagnoses revealed there were no diagnosis relating to a fracture of the leg noted in the medical records. Review of Resident #195's care plans dated 07/26/24 revealed no focus for the plan of care for a walking cast. Review of Resident #195's physician orders revealed no orders for a walking cast. Observation and interview on 08/05/24 at 11:22 A.M. with Resident #195 revealed the resident was alert and oriented. Resident #195 stated she was wearing the walking boot due to having a broken foot. Resident #195 stated she was not informed of any care plans regarding the walking cast and stated she did not know when the walking cast was to be removed. Resident #195 denied any issues with her skin on her right leg but stated she was unsure of the actual condition of the skin. Interview on 08/07/24 at 8:49 A.M. with Licensed Practical Nurse (LPN) #321 verified there was no care plan or physician orders relating to Resident #195's walking cast. Per LPN #321, the resident stated she had a broken foot. LPN #321 verified there was no diagnosis for the resident's right leg noted in the medical records. Interview on 08/07/24 at 9:46 A.M. Regional Clinical Services (RCS) #602 verified there were no orders, no care plans, and no diagnoses in regards to Resident #195's walking cast. Per RCS #602, the resident was admitted with the cast and there have been no skin assessments or care plans for the care of the resident's leg. Review of the facility policy titled, 'Comprehensive Care Plan', dated 11/2016, revealed the (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 7 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 08/08/2024 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)