Cycle 1
Health 2024-08-08 · Fire 2024-08-08
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Coldwater, OH
Briarwood Village
2-star overall rating with 1-star inspections with $26,685 in total fines with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
100 Don Desch Drive, Coldwater, OH
(419) 678-2311
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hcf Management
Operator or chain grouping
Approved since
1976-12-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.65
Licensed practical nurse staffing
Aide hours / resident day
2.03
Nurse aide staffing
Weekend hours
2.74
Weekend nurse staffing
RN turnover
74%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.8% |
92.4%
23.6 pts worse
|
93.4%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
94.5%
1.2 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
3.3%
4 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
26.1%
23.6 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
25.4%
4.2 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
11.5%
0.8 pts better
|
16.7%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
7.7%
5 pts worse
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
6.2%
7 pts worse
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
21.7%
3.2 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
3.7%
2 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.3% |
78.1%
41.8 pts worse
|
81.7%
45.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.5%
0.9 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.2%
1.9 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.4% |
75.6%
47.2 pts worse
|
79.7%
51.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
25.1%
8.7 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-25 · Fire 2022-10-25
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-01-16 · Fire 2020-01-16
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-30
E · Potential for more than minimal harm
2024-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-30
C · Minimal harm
2024-08-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-08-28
F · Potential for more than minimal harm
2022-10-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-15
F · Potential for more than minimal harm
2022-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-15
F · Potential for more than minimal harm
2022-10-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-15
F · Potential for more than minimal harm
2020-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-14
F · Potential for more than minimal harm
2020-01-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2020-02-14
E · Potential for more than minimal harm
2020-01-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-26
D · Potential for more than minimal harm
2025-09-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-26
J · Immediate jeopardy
2025-08-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-04-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-10-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-08-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-28
F · Potential for more than minimal harm
2024-08-08
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-08-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-28
F · Potential for more than minimal harm
2022-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-15
E · Potential for more than minimal harm
2022-10-25
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-15
D · Potential for more than minimal harm
2022-10-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-15
E · Potential for more than minimal harm
2020-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-02-14
E · Potential for more than minimal harm
2020-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-02-14
E · Potential for more than minimal harm
2020-01-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-02-14
E · Potential for more than minimal harm
2020-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-02-14
D · Potential for more than minimal harm
2020-01-16
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-02-14
Penalties and ownership
What sits behind the stars
$26,685
2025-08-14
Fine
Fine · fine $26,685
Fine
Ownership
Hcf Operations, Inc
5% Or Greater Direct Ownership Interest · Organization
Chad M. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Chappel, Margo
Operational/Managerial Control · Individual
Chappel, Margo
Corporate Director · Individual
David V. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Hcf Management, Inc.
Operational/Managerial Control · Organization
Hcf, Inc
5% Or Greater Indirect Ownership Interest · Organization
Hunter, Rachel
Operational/Managerial Control · Individual
Jeffrey L. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-29-04 Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kendra M. U
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kerri A. Ro
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kevan R. Un
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kristen S.
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kyle J. Unv
5% Or Greater Indirect Ownership Interest · Organization
Joseph L. Unverferth 12-15-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Klay, Celeste
Corporate Director · Individual
Klay, Celeste
Corporate Officer · Individual
Lawrence G. Unverferth 12-13-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
R. Steven Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Romes, Kerri
Operational/Managerial Control · Individual
Romes, Kerri
Corporate Director · Individual
Romes, Kerri
Corporate Officer · Individual
Shaw, Anthony
Operational/Managerial Control · Individual
Shaw, Anthony
Corporate Officer · Individual
Unverferth, Chad
Operational/Managerial Control · Individual
Unverferth, Chad
Corporate Officer · Individual
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4-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Gardens At Celina
Celina, OH
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