Briarwood Village

Inspectors wroteBased on review of resident council meeting minutes and staff interview, the facility failed to respond to resident concerns addressed in resident council meetings. This affected two residents (#242 and #249) of four residents reviewed for Resident Council. The facility census was 95.1. Review of the Resident Council Meeting Minutes (RCMM) dated 07/01/25 revealed concerns with the dietary department. Further review revealed there was no evidence of action taken to address residents' concerns. Interview on 09/15/25 at 12:12 P.M. with the Administrator verified she was unable to locate evidence of staff action taken in response to concerns brought up by residents during the August 2025 Resident Council Meeting (RCM). 2. Review of the RCMM for 08/05/25 revealed residents' voiced concerns of receiving their medications late on the weekends due to nurse helping the aides. [...]

Inspectors wroteBased on medical record review, resident interviews, and staff interviews, the facility failed to complete residents' showers as scheduled. This affected three residents (#249, #242, and #212) of three residents reviewed for showers. The census was 951. Review of the medical record for Resident #249 revealed an admission date of 03/06/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 a Brief Interview for Mental Status (BIMS) score of eight, indicating impaired cognition. He required set-up or clean up assistance for Activities of Daily Living (ADLs). Review of Resident #249's shower sheets for the past 14 days revealed the following: 09/02/25 not applicable, 09/05/25 no shower given, 09/25/25 shower given, and 09/12/25 not applicable. [...]

Inspectors wroteBased on observation, medical review, staff interview, and review of a facility policy, the facility failed to follow infection control procedures for a resident positive with COVID-19. This affected one (Resident #249) of one resident reviewed for COVID-19 precautions. The facility census was 62. Review of the medical record for Resident #249 revealed an admission date of 03/06/23. The resident was admitted with diagnosis of COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of eight, indicating moderately impaired cognition. This resident was assessed to require set or clean-up assistance for bathing, dressing, and toileting. Review of the progress note dated 09/09/25 revealed Resident #249 tested positive for COVID-19 and was placed in droplet isolation for ten days. Observation on 09/15/25 at 10:00 A.M. [...]

Inspectors wroteBased on observation, medical record review, staff interview, review of facility investigation, physician interview, review of bed user service manual, and policy review, the facility failed to ensure Resident #01 was provided adequate supervision during the provision of activities of daily living. Resident #01 was cognitively impaired, and dependent on staff for transfer and bed mobility with bilateral lower extremity contractures. This resulted in Immediate Jeopardy, actual harm and death beginning on [DATE] at 10:11 A.M. when two Certified Nurse Aides (CNA) directed attention away from Resident #01, who was lying in bed on her left side with the bed elevated. [...]

Inspectors wroteBased on medical record review, staff interview, local health department staff interview, and review of facility policy, the facility failed to report norovirus cases and multiple resident's gastrointestinal (GI) symptoms (nausea/vomiting/diarrhea) to the local health department. This had the potential to affect all 92 residents of the facility. The census was 92.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staffing record review, and staff interviews, the facility failed to employ a Director of Nursing (DON) full time at the facility. This had the potential to affect all 86 residents.

Inspectors wroteBased on employee file review and interview the facility failed to ensure State Tested Nursing Assistant (STNAs) had 90 day evaluations and/or annual performance evaluations. This affected four of six employee files reviewed. This had the potential to affect all residents. The facility census was 99.

Inspectors wroteBased on employee file review, interview, and policy review, the facility failed to ensure State Tested Nursing Assistants (STNAs) completed 12 hours of education. This affected two of three STNA files reviewed for annual training. This had the potential to affect all residents. The facility census was 99.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview, the facility failed to monitor bruises once observed. This affected one resident (#59) of one resident reviewed for bruising. The facility census was 99.

Inspectors wroteBased on observation, Medscape review, medical record review, interview, and policy review, the facility failed to ensure residents did not receive outdated insulin. This affected one (Resident #30) of two residents reviewed for insulin. The facility census was 99.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were not left at the bedside. This affected one (Resident #26) of one residents observed. The facility census was 99.

Inspectors wroteBased on observation, staff interview, review of the kitchen daily cleaning schedule, and policy review, the facility failed ensure foods were labeled and dated, discard expired foods, and resident meals trays were covered during transport to resident rooms. In addition, the kitchen area and equipment was not maintained in a sanitary manner. This had the potential to affect all residents who resided in the facility and received food from the kitchens. The facility census was 73.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were stored at proper temperatures. This affected 15 residents (#11, #56, #14, #42, #14, #48, #34, #26, #15, #13, #61, #07, #06, #37 and #274) and had the potential to affect all 59 residents on the A, B, C, and D halls. The facility identified three resident medication refrigerators. The facility census was 73.

Inspectors wroteBased on staff interview and review of personnel files, the facility failed to provide newly hired State Tested Nurse Aides (STNA) with training on caring for residents with a diagnosis of dementia. This had the potential to affect 44 residents (#41, #51, #40, #328, #50, #27, #30, #48, #68, #277, #26, #60, #03, #07, #39, #69, #17, #56, #38, #12, #06, #19, #374, #62, #04, #28, #63, #70, #46, #08, #35, #37, #02, #29, #31, #15, #47, #36, #18, #67, #22, #124, #375, and #13) out of 44 residents diagnosed with dementia. The facility census was 73.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure resident rooms remained clean. This affected two residents (#21 and #64) out of 73 residents' rooms observed. The facility census was 73.

Inspectors wroteBased on medical record review, observation, and staff and family interview, the facility failed to ensure a comprehensive skin assessment was completed on residents. This affected one resident (#46) out of 18 residents sampled. The facility census was 73.

Inspectors wrote2. Review of the medical record of Resident #38 revealed an admission date of 11/11/15. Diagnoses included other speech disturbances, unspecified hydrocephalus, contusion of left knee sequela, unspecified constipation, other dysphagia, unspecified systolic (congestive) heart failure, paroxysmal atrial fibrillation, non-ST elevation myocardial infarction, and rhabdomyolysis. Review of the PAS (Pre-admission Screen) Review dated 04/11/13 revealed Resident #38 had no indications of serious mental illness nor a developmental disability. Review of the medical record revealed a diagnosis of unspecified psychosis not due to a substance or known physiological condition dated 09/27/17, and a diagnosis of unspecified dementia, unspecified severity with agitation dated 10/03/22. The record had no documentation of any additional PAS Reviews were completed. Interview on 10/20/22 at 1:35 P.M. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an actual skin concern was developed in the plan of care. This affected one resident (#46) out of 18 residents sampled. The facility census was 73.

Inspectors wroteBased on medical record review, observation, and resident and staff interviews, the facility failed to ensure dependent residents were repositioned. This affected one resident (#39) out of one resident reviewed for positioning. The facility census was 73.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure pressure ulcers were accurately assessed and documented treatment in place. This affected one resident (#46) out of three residents reviewed for pressure ulcers. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were limited to 14 days, and failed to ensure a physician evaluated the resident before continuing a PRN psychotropic medication. This affected two residents (#48 and #66) out of seven residents reviewed for unnecessary medications. The facility census was 73.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.