Health inspection·August 14, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. documentation and assessments post fall. All 46 licensed nurses and CNAs were educated by [DATE]. On [DATE], the SDC #95, Physical Therapy Assistant (PTA) #109 and CNA #106 completed competencies for all 46 licensed nurses and CNAs nursing staff regarding bed mobility, turning and repositioning and safely caring for residents in bed. On [DATE], the DON, Regional Nurse #103, Staff Development Coordinator (SDC) #95 and Case Manager #97 audited all residents who had falls within the past 30 days to ensure appropriate investigation and fall interventions in place in room and on care plan. On [DATE], SDC #95 and DON reeducated all 46 licensed nurses and CNAs to ensure adequate supervision in accordance with the resident's plan of care is provided during the provision of resident activities of daily living (ADL). Staff not educated by [DATE] will not be permitted to work until education completed. On [DATE], Regional Nurse #103, DON and Minimum Data Set (MDS) Nurse #114 completed care plan audits on all 43 residents who were totally staff dependent for all ADL care while in bed to ensure all fall risk assessments were up to date and to ensure care plans accurately reflect assessment and fall risk interventions. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted with Interdisciplinary Team (IDT) which included ED #34, Administrator, Human Resources Manager #115, MDS Nurse #114, Restorative Nurse #117, DON, and Medical Director #130 to discuss the incident and follow-up interventions in response to corrective actions that the facility needed to complete to keep their residents safe in the future. On [DATE], Regional Director of Operations #135 and Regional Nurse #103 educated ED #34, Administrator and DON on the need to ensure that investigations of falls are thorough. Beginning [DATE], the DON or designee will conduct daily observations of three residents receiving ADL care (e.g., bedside care, transfers, toileting, etc.) to ensure that supervision is being provided during the activity in accordance with the plan of care and resident needs. The audits will be completed daily for two weeks on varying shifts, and three days a week on varying shifts for four weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance.Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included cerebral ischemia, anxiety disorder, and cardiomegaly. Review of the nursing plan of care, dated [DATE], revealed Resident #01 was at risk for falls related to decreased mobility, use of psychoactive medications, and incontinence. Interventions included anticipating and meeting Resident #01's needs, Resident #01 needs a safe environment with bed in low position at night, and personal items in reach. Review of the physician orders, dated [DATE], revealed an order for the use of a mechanical lift (Hoyer) for all transfers and a low air loss mattress placed to bed. There was no documentation in the medical record that Resident #01 was assessed for proper use of the bed or mattress. Review of the fall risk assessment dated [DATE] revealed Resident #01 was at a fall risk. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #01 was cognitively impaired and was dependent on staff for rolling side to side, bed mobility, and transfers. Resident #01 was always incontinent with bowel and bladder and did not have any falls during the review period. Resident #01 had lower leg contractures. Resident #01 was often non-compliant with care and frequently refused. Review of the progress note documented as a late entry on [DATE] at 10:11 A.M. revealed Licensed Practical Nurse (LPN) #69 heard CNA #61 yell out from Resident #01's room. Resident #01 was on the floor, on her left side beside her bed. Resident #01 was holding her head, and a pool of blood was on the floor. Resident #01 was moving around and was visibly upset about getting blood into her hair. LPN #69 looked at Resident #01's head and observed a laceration and called for Registered Nurse (RN) #83 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365341 If continuation sheet Page 2 of 5 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 08/14/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. assess the resident. As RN #83 came into the room, LPN #69 contacted Physician Assistant (PA) #22 to obtain order to send the resident out to the emergency room (ER). LPN #69 called 911 and contacted the local hospital emergency room to provide report. LPN #69 met one squad member before returning to Resident #01's room. Upon her return to the room, Resident #01 was up in the wheelchair and the laceration had stopped bleeding. Resident #01 was taken to the local hospital for evaluation. This note was created as a late entry on [DATE] at 10:54 A.M. Review of the progress note dated [DATE] at 10:15 A.M., written by RN #83, revealed two CNAs (#61 and #89) had been assisting Resident #01 with incontinence care. Both CNAs had turned away from the bed to gather trash and the wheelchair when Resident #01 became upset and rolled herself from the bed, yelling as she fell. The two CNAs yelled for the nurse, who responded immediately, and then alerted RN #200. Resident #01 was contracted and transferred using a mechanical lift. Upon the nurse's arrival at the bedside, Resident #01 was lying on her left side with blood around her head. A laceration was noted to the left top side of head and a skin tear to the left elbow. Vital signs were stable, and Physician Assistant (PA) #22 was notified and ordered Resident #01 to be sent to the hospital for evaluation. Resident #01's daughter was also contacted. Review of the hospital note dated [DATE] at 10:59 A.M. revealed Resident #01 stated she was trying to get off the bed when she fell and hit the floor. Resident #01 reported hitting the top of her head without loss of consciousness. She complains of laceration and pain to the top of head and posterior neck. Assessment identified a four plus centimeter (cm) laceration that was subcutaneous on top of the head. Procedures included six staples placed to approximate the head wound edges. The computerized tomography (CT) results dated [DATE] revealed a closed displaced fracture of first cervical vertebra, closed odontoid fracture with type II morphology and posterior displacement. Follow-up recommendation was to assess cord compression. Physician consultation with Resident #01 and the responsible party requested no further treatment and hospice services would be obtained. Resident #01's responsible party refused higher level of care for evaluation for the cervical spine fractures. Resident #01 and responsible party understood the adverse outcomes including paralysis and cord injury. Resident #01 will be discharged back to the facility with hospice care. Resident #01 returned to the facility on [DATE] and was admitted under hospice care as discussed between the hospital physician and hospice physician due to cervical spine fractures. Resident #01 was non-compliant with wearing the c-collar. Resident #01's daughter took off the c-collar because the resident didn't want to wear it. Resident #01 expired in the facility on [DATE]. Review of incident report dated [DATE] noted Resident #01 rolled out of bed during check and change during agitated behavior towards staff. Review of the facility's investigation into the fall revealed Resident #01 was oriented to person, place and time. A note documented Resident #01 rolled out of bed during check and change and displayed agitated behavior towards staff. The facility identified the root cause was accidental and completed education on transferring. Review of CNA #89's written statement, dated [DATE], revealed CNA #61 and CNA #89 were changing Resident #01. After the resident was cleaned up and dressed, CNA #89 turned around to get the trash and CNA #61 went to get the wheelchair by the television (TV). CNAs #61 and #89 heard Resident #01 start to scream and turned around and she was rolling off the bed. CNA #89 ran and tried to catch her but did not make it in time to fully catch her before she hit the floor. CNAs #61 and #89 yelled for LPN #69 to come right away. Review of CNA #61's written statement, dated [DATE], revealed CNAs #61 and #89 were changing Resident #01 on her bed. When they were done changing the resident, Resident #01 was laying down. CNA #89 turned to take trash bag out of trash can and CNA #61 turned around to grab the wheelchair placed by the TV. CNAs #61 and #89 heard Resident #01 scream and turned around and Resident #01 was rolling off the bed. CNA #89 tried catching her but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365341 If continuation sheet Page 3 of 5 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 08/14/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. missed. LPN #69 immediately came to the room. The facility's investigation did not include an assessment of the bed and low air loss mattress, how Resident #01 was positioned in the bed, explain how Resident #01 could fall from her bed when she was dependent on staff rolling side to side and had bilateral leg contractures that were pulled up to the torso, did not identify CNAs #61 and #89 left Resident #01 unsupervised in a elevated bed, and did not identify Resident #01's root cause of the fall. The progress note dated [DATE] at 8:20 P.M. revealed Resident #01 was without vital signs. Review of the death certificate revealed the immediate cause of death was moderate to severe cervical canal stenosis with immediate cause of acute odontoid process fracture with comminuted first cervical body fracture. The approximate interval from onset and death was two days for the immediate causes of death. During an interview on [DATE] at 7:35 A.M., Maintenance Director #21 stated Resident #01 was on an air mattress owned by the facility. During an observation with Maintenance Director #21 at 10:10 A.M., the air mattress energized and operated (inflated) as designed with the firm setting. The air mattress edges (perimeters) compressed with little pressure or resistance. During an interview on [DATE] at 9:25 P.M., Director of Therapy (DT) #20 stated during a review of Resident #01's most recent occupational therapy (OT) Discharge summary dated [DATE], Resident #01 was assessed with bilateral lower extremity contractures and no lower extremity mobility. DT #20 stated Resident #01 was unable to position herself side to side due to contractures and legs being fixed in the flexed position (pulled up toward torso). Resident #01 was dependent on staff on mechanical lift transfers using two staff. DT #20 also confirmed Resident #01's bed and mattress were assessed by nursing to determine appropriated use. During an interview on [DATE] at 9:43 A.M., PA #22 stated Resident #01 required assistance with care. PA #22 stated Resident #01 was mostly seated in a wheelchair when observed. PA #22 stated she was informed resident fell and was bleeding. PA #22 placed an order to send Resident #01 to the ER. PA #22 reviewed hospital progress notes related to the incident and stated Resident #01 and her responsible party chose to go on hospice due to refusing further medical intervention for cervical fractures. Resident #01 was an unreliable historian with moderate cognitive impairment. PA #22 stated no further involvement or contact with Resident #01 occurred after the telephone order was given to have the resident sent to the ER on [DATE]. Further medical record review also confirmed the record lacked documentation by the primary physician following the [DATE] incident. During an interview on [DATE] at 11:01 A.M., CNA #45 stated on [DATE] at approximately 10:00 A.M. she was aware that CNA #61 and #89 were in Resident #01's room with the door closed. CNA #61 screamed from Resident #01's door for LPN #69. LPN #69 and RN #83 responded. CNA #45 entered the room and Resident #01 was observed with blood coming from the top of her forehead. No blood was observed on the dresser located next to the left side of the bed. Resident #01 was on left side of bed on the floor facing toward the room entry. Resident #01 was alert. With her head next to dresser within two inches. Resident #01's bed was elevated to approximately 36 inches. During an interview on [DATE] at 11:24 A.M. via telephone, CNA #61 stated on [DATE] Resident #01 needed changed. Resident #01 was on her bed and positioned on her left side. CNA #61 was standing on the left side of the bed with the bed elevated to approximately three feet from the floor. The bed was elevated to provide staff with sufficient access to Resident #01 which occurred during care. CNA #89 was standing on the right side of the bed. CNA #61 turned around to get the mechanical lift sling from the wheelchair which was located approximately one foot from the foot of the bed. At the same time CNA #89 left the right side of the bed and proceeded to the left side of the bed to obtain a trash can. CNA #61 confirmed CNAs #61 and #89 were not visualizing Resident #01 at that moment. Resident #01 screamed and proceeded to roll out of the left side of the bed onto floor. CNA #61 ran to the door of room and yelled for LPN #69 who was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365341 If continuation sheet Page 4 of 5 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 08/14/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete just outside door. CNA #61 verified Resident #01's bed was elevated at the time of the incident and both CNAs turned away from Resident #01 at the time of the incident. During an interview on [DATE] at 12:30 P.M., the DON confirmed the air mattress that was applied to Resident #01's bed provided little to no perimeter resistance when pressure was applied to the mattress edge. Additional interview verified no documentation contained in the medical record indicated Resident #01's air mattress or bed were assessed for appropriate use. During an interview on [DATE] at 1:05 P.M. via telephone, Hospice Physician #2 revealed the primary cause of Resident #01's death was due to cervical fractures sustained from the fall from bed on [DATE]. During an interview on [DATE] at 11:06 A.M. via telephone, CNA #89 confirmed Resident #01's bed was elevated approximately three feet when Resident #01 fell from the bed on [DATE]. CNA #89 walked around the foot of the bed to the left side of the bed and proceeded to access a trash can located at the left side of the bed. CNA #89 confirmed she took her visual focus away from Resident #01 while tending to the trash receptacle which left the resident unattended while in a elevated bed. CNA #89 responded to Resident #01 yelling out and observed the resident rolling from bed. CNA #89 lunged towards Resident #01. However, the resident proceeded to fall to the floor and sustained an injury to the head. CNA #89 confirmed she received training related to the transfer and use of mechanical lifts. However, no training included maintaining supervision to prevent accidents. Review of the policy titled Fall Reduction Policy, approved [DATE], revealed based on the outcome of fall assessments, a fall risk reduction plan will be incorporated into the resident's plan of care. The interdisciplinary team will review the residents' fall risk reduction plan at a quarterly minimum, during care conference and modify the plan as needed, based on the resident's functional status during the review period. Referrals will be made to other health professionals as needed. Follow-up investigations will be carried out to ascertain the cause of the incident to reduce the risk of further occurrences. Employee education will include body mechanics, transfer/ambulation techniques, transfer/ambulation equipment and assistive devices, maintenance of equipment and assistive devices. Review of the manual titled Joerns User-Service Manual dated 2023, documented important precautions included the following: Keep bed in lowest position except when providing care. Bed should be at lowest convenient height for entry or exit. Failure to do so could result in injury. Use of an improperly fitted mattress could result in injury or death. An optimal bed system assessment should be conducted on each resident by qualified clinician or medical provider to ensure maximum safety of the resident. This deficiency represents non-compliance investigated under Complaint Number 2565060. Event ID: Facility ID: 365341 If continuation sheet Page 5 of 5