Health inspection·April 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of the Ohio Department of Health (ODH) Application Gateway, the facility failed to report an incident of resident-to-resident physical abuse to the state agency. This affected one (#19) of three residents reviewed for abuse. The census was 92. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 11/30/21. Diagnoses listed included Alzheimer's disease, psychotic disorder, hearing loss, and generalized anxiety disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was rarely understood by staff. Review of progress notes revealed on 03/21/25 at 8:30 P.M. Resident #19 was walking with her walker and came to stop in front of of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at Resident #19. A third resident came into the area and told Resident #19 to move. Resident #19 has confusion, and did not move. The resident sitting in the nearby chair began yelling more. The third resident then used her elbow and struck Resident #19 in the upper right arm, then immediately after doing so, placed both hands onto the resident's arm and pushed. Resident #19 stumbled but did not fall. The nurse was able to reach the residents before it escalated any further. The nurse removed Resident #19 from the area to ensure safety. No evidence of any injury was noted. 2. Review of Resident #23's medical record revealed an admission date of 11/30/21. Diagnoses listed included dementia, type II diabetes mellitus, atrial fibrillation, and major depressive disorder. Review of a annual MDS dated [DATE] revealed Resident #23 was severely cognitively impaired. Review of progress notes revealed on 03/21/25 at 8:30 P.M. a resident with a walker came to a stop in front of an empty recliner in the common area. A resident sitting in a nearby chair began yelling at the resident. Resident #23 came into the area and told the resident with the walker to move. The resident with the walker has confusion, and did not move. The resident sitting in the nearby chair began yelling more. Resident #23 then used her elbow and struck the resident with the walker in the upper right arm, then immediately after doing so, placed both hands onto the resident with the walker's arm and pushed. The resident with the walker stumbled but did not fall. The nurse was able to reach the residents before it escalated further. The nurse removed the resident with the walker from (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 4 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 04/07/2025 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)