Briarfield Manor: Fall Investigation Failures - OH
Resident #72 was at moderate risk for falls and required supervision for eating and personal hygiene. She needed partial to moderate assistance with toileting and showering, and was occasionally incontinent. Her care plan identified muscle weakness, a history of falls, and difficulty walking as risk factors.
On May 15, staff found her on the floor in front of her wheelchair in her room. She told them she was attempting to walk on her own and lost her balance, hitting her head on the floor. Staff noted a red area on her left hip and left upper head.
The nursing note stated her vital signs were "within normal limits" but provided no actual measurements. The facility's incident report made the same claim about both vital signs and neurological checks, but inspectors found neither were actually documented.
Her daughter requested she be sent to the emergency room.
The incident report revealed an alarm was sounding when she fell, though she had no physician's order for an alarm. Staff listed her as confused but oriented to person. The investigation found no evidence her call light was within reach, despite her care plan requiring it.
Two months later, on July 11, staff found Resident #72 on the floor again. This time she showed more concerning symptoms. She was confused and unable to answer questions. She could not follow a light with her eyes.
Staff sent her to the emergency room and notified her daughter, son, physician, and director of nursing.
The second incident report documented actual vital signs: blood pressure 116/70, pulse ox 99%, temperature 97.9 degrees, heart rate 80, with no reported pain. But once again, staff claimed neurological checks were "within normal limits" without providing any documentation of what those checks revealed.
The resident could not indicate whether she hit her head. Staff noted she was confused, with predisposing factors including incontinence, gait imbalance, and not using her call light for assistance.
The investigation failed to determine whether her call light was within reach or when she was last toileted.
Director of Nursing confirmed during an August 25 interview that Resident #72 had no physician's order or care plan addressing bed or chair alarms, despite the alarm that sounded during her first fall.
She acknowledged the facility's fall investigations "likely needed to be updated to ensure accuracy and thoroughness." She said they should have included all interventions in place at the time of falls to determine root causes.
The facility's own Fall Prevention Policy required staff to document and evaluate any fall, including when and where it occurred and observations of the event. Staff were supposed to assess and document vital signs, recent injuries, neurological status, precipitating factors, and details of how falls occurred.
The policy specifically required nurses to assess patients' vital signs, range of motion, and any injuries, as well as identify environmental factors that may have contributed to the fall.
Inspectors found the facility failed to follow its own procedures in both incidents involving Resident #72.
The falls occurred despite interventions supposedly in place, including ensuring her call light was within reach and maintaining clear pathways. Staff were also supposed to position quarter-top positioning bars when she was up in bed to aid in positioning.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. The investigation stemmed from a complaint filed against the facility.
Both falls resulted in emergency room visits for a resident already struggling with cognitive impairment and physical limitations. The missing documentation meant staff could not properly analyze what went wrong or prevent future incidents.
The facility's failure to follow its own fall prevention policies left Resident #72 at continued risk, with inadequate investigation into why a vulnerable resident kept falling despite supposed safety measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Briarfield Manor from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
BRIARFIELD MANOR in YOUNGSTOWN, OH was cited for violations during a health inspection on August 27, 2025.
Resident #72 was at moderate risk for falls and required supervision for eating and personal hygiene.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.