Briarwood Village
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
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 REDACTED] 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 REDACTED] 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 REDACTED]. During an interview on [DATE REDACTED] 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 REDACTED].
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 REDACTED], 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.
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BRIARWOOD VILLAGE in COLDWATER, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLDWATER, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRIARWOOD VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.