Avenue at Brooklyn

Inspectors wroteBased on medical record review, Self-Reported Incident (SRI) investigation review, video surveillance review, police report review, Ohio Board of Nursing complaint information, interviews, and facility policy review, the facility failed to implement adequate interventions to prevent a fall, prevent accident hazards to prevent injury, conduct a safe resident transfer to prevent injury, provide appropriate assessment and care after a fall, and complete timely and accurate fall assessments, investigations and care plans. This affected five residents (Residents #6, #24, #56, #113 and #115) of seven residents reviewed for accidents. The facility census was 95. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews of nursing staff schedules, timecards, facility assessment and Payroll Based Journal, the facility failed to maintain sufficient staffing levels to ensure residents received timely care and services. This affected eight residents (Resident #6, #12, #13, #16, #39, #40, #93 and #99) and had the potential to affect all 95 residents residing in the facility.

Inspectors wroteBased on the nursing staffing schedule, staff time punches and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 95 residents residing in the facility.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure effective administration staff. This affected 30 residents (Residents #6, #9, #12, #13, #16, #24, #25, #29, #30, #32, #39, #40, #45, #49, #56, #61, #72, #80, #82, #83, #86, #88, #93, #96, #99, #106, #110, #113, #115 and #117) and had the potential to affect all residents residing in the facility. The facility census was 95.

Inspectors wroteBased on record review, observation, staff interview, video surveillance review, police report review, and review of the facility's policies, the facility failed to implement care planned interventions and provide required assistance for multiple activities of daily living (ADL). Specifically, the facility failed to provide timely incontinence care for Residents #16, #45, #93, and #110; failed to ensure Resident #45's fingernails were trimmed appropriately; failed to ensure Resident #16's mattress remained properly positioned; failed to ensure Resident #110 received needed meal assistance; and failed to ensure scheduled showers were provided for Residents #45 and #88. This deficient practice affected five residents (#16, #45, #88, #93, and #110) out of seven residents reviewed for ADL. The facility census was 95.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents were provided with adaptive equipment to maintain independence. This affected three residents (Residents #29, #80 and #86) of four residents who received adaptive equipment for drinking. The facility census was 95.

Inspectors wroteBased on record review, observation, interview, review of a concern form, and review of the facility policy, the facility failed to ensure Resident #93 was free from staff-to-resident verbal abuse. This affected one resident (Resident #93) out of four residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on record review, review of the Medicaid Information Technilogy System (MITS), review of the Ohio Department of Medicaid Bureau of Long-Term Services and Supports application of Shared of Cost/Patient Liability for Nursing Facilities, review of Ohio Department of Health (ODH) documentation, review of a facility Self-Reported Incident (SRI), and interview, the facility failed to ensure Resident #61 was free from misappropriation of resident funds and Resident #117 was free from misappropriation of personal property. This finding affected two (Residents #61 and #117) of ten residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on resident record review, staff interviews, Self-Reported Incident (SRI) review, review of the police report, review of hospital paperwork, and facility policy review, the facility failed to implement the abuse policy related to an injury of unknown origin for Resident #56. This affected one (Resident #56) of one resident reviewed for injuries of unknown origins. The facility census was 95.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to report abuse allegations to the State Agency. This affected three residents (Residents #82, #93 and #117) of ten residents reviewed for abuse. The facility census was 95.

Inspectors wroteBased on medical record review, interview, and review of facility policy the facility failed to ensure physician orders were followed for appointments. This affected one resident (Resident #13) of three residents reviewed for coordination of care. The facility census was 95.

Inspectors wroteBased on observations, resident record review, staff interviews, and facility policy review, the facility failed to provide timely incontinence care Resident #13. This affected one (Resident #13) of one resident reviewed for incontinence care. The facility census was 95.

Inspectors wroteBased on record review, observation, interview, review of hospital records, review of therapy records, and review of the facility policy, the facility failed to ensure Resident #45's care planned interventions were implemented and physician orders were followed for eating assistance and adaptive equipment. This affected one (Resident #45) out of three residents reviewed for feeding assistance. The facility census was 95.

Inspectors wroteBased on medical record review, observation, interview, review of dialysis transfer agreement, and facility policy review, the facility failed to ensure residents were transported to dialysis treatments. This affected one resident (Resident #106) of one resident reviewed for dialysis services. The facility census was 95.

Inspectors wroteBased on medical record review, interviews, and facility policy review, the facility failed to ensure medication orders were transcribed accurately to prevent a significant medication error. This affected one resident (Resident #88) of six residents reviewed for medication administration. The facility census was 95.

Inspectors wroteBased on record review, observation, and interview, the facility failed to honor food preferences by not serving foods documented as an allergy. This affected one resident (Resident #83) of one resident reviewed for food preferences. The facility census was 95.

Inspectors wroteBased on record review, interview, observation, and facility policy review, the facility failed to provide substantial nutritional evening snacks when mealtimes were greater than 14 hours. This affected three residents (Residents #49, #96 and #99) of 20 residents (Residents #4, #25, #29, #30, #41, #48, #49, #59, #76, #78, #86, #89, #90, #92, #94, #96, #98, #99, #100 and #102) who reside on the memory care unit and receive meals from the kitchen. The facility census was 95.

Inspectors wroteBased on medical record review, observation, interview, and facility policy review, the facility failed to ensure shower sheets were not falsified for one resident (Resident #88) of five reviewed for showers. The facility census was 95.

Inspectors wroteBased on closed medical record review, review of an Emergency Medical Services (EMS) report, facility policy review and interview, the facility failed to timely identify and provide adequate and necessary care for Resident #104, who experienced an acute change in condition. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] when the facility failed to recognize and failed to timely and adequately respond to Resident #104's report of a low blood glucose level. On [DATE], at 12:18 A.M., Resident #104, who was known by staff to be a brittle diabetic, activated her call light and Certified Nursing Assistant (CNA) 636 responded. Resident #104 reported she needed a snack because her blood glucose level was low. [...]

Inspectors wroteBased on observation, resident record review, resident interview, and staff interview, the facility failed to ensure residents were treated with respect and dignity. This affected three residents (#30, #31, and #87) of three reviewed for respect and dignity. The facility census was 103.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to have less than 5 percent (%) medication error rate. Three errors out of twenty-nine opportunities were observed resulting in an error rate of 10.34 %. This affected three residents (#5, #35, and #107) of five residents observed for medication administration.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#5) out of five residents reviewed for medication administration. The facility census was 103.

Inspectors wroteBased on observations, staff interview, and review of the facility policy and procedures revealed the facility failed to ensure the kitchen and nursing unit refrigerators were maintained in a clean and sanitary manner. This had the potential to affect all residents except one resident (#33) who received nothing by mouth. The facility census was 105.

Inspectors wroteBased on observation, staff interview, and review of the facility policy and procedures, the facility failed to ensure the outside dumpster area was maintained in a sanitary manner free from debris. This had the potential to affect all residents. The facility census was 105.

Inspectors wroteBased on record review, staff interview, and review of facility arbitration the facility failed to ensure its arbitration agreement contained all required information. This affected all residents. The facility census was 105.

Inspectors wroteBased on record review, staff interview and review of facility arbitration agreement revealed the facility failed to provide a neutral and fair arbitration process by ensuring both the resident or the resident representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties. This affected all residents. The facility census was 105.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice residents in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. This affected five residents (#8, #43, #80, #98 and #303) of five residents residing in the facility with diagnoses of post traumatic stress disorder (PTSD). The facility census was 105.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure a referral for an appointment to ear, nose, and throat (ENT) was made timely for Resident #12. This affected one resident (#12) of two residents reviewed for vision and hearing. The facility census was 105.

Inspectors wroteBased on record review, staff interview, and review of the facility policy and procedure the facility failed to ensure consistent communication between the facility and dialysis with the dialysis communication forms. This affected one resident (#12) of one resident reviewed for dialysis. The facility census was 105.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide timely incontinence care for Resident #22. This affected one (Resident #22) of two residents reviewed for incontinence care. The facility census was 105.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to administer medications as ordered and failed to ensure medication orders included appropriate dosage, creating a medication error rate above 5%. This affected one (Resident #25) of two residents reviewed for medication administration. The facility census was 105.

Inspectors wroteBased on record review, and interviews the facility failed to provide appropriate and timely ongoing communication between the facility and hospice for one resident (Resident #63) of three residents reviewed for Hospice services. The facility identified eight residents receiving hospice services. The facility census was 105.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected three (Residents #85, #95 and #304) of three residents review of appropriate beneficiary notices. The facility census was 105.

Inspectors wroteBased on observation, interview, review of the medical record and review of the facility policy, the facility failed to ensure appropriate handling and transport or soiled linens after providing incontinence care to Resident #37. This affected one resident (#37) and had the potential to affect an additional 12 residents (#20, #36, #40, #41, #49, #55, #72, #87, #88, #89, #90, and #92) who were to receive care and services from Certified Nurse Aide (CNA) #300. The facility census was 103.

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure all intravenous (IV) antibiotics were administered to resident #6 as ordered by the physician. This affected one resident (#6) of three residents reviewed for medication administration. The facility census was 103.

Inspectors wroteBased on record review and interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on closed medical record review, review of a Prehospital Care Report Summary/EMS Run report, review of the American Heart Association Cardiopulmonary Resuscitation (CPR) guidelines, facility policy review, interview with Emergency Medical Service (EMS) staff, staff interview and family interview, the facility failed to ensure all staff provided effective cardiopulmonary resuscitation (CPR). Additionally, the facility failed to ensure crash carts (a cart that holds equipment and includes a backboard, a hard, flat surface to facilitate effective chest compressions and an ambu bag, used to provide mechanical ventilation) in emergency resuscitation efforts were readily available and accessible during a cardiac emergency. [...]

Inspectors wroteBased on closed medical record review, review of an Emergency Medical Services (EMS) Run report, review of the Health Care Summary, facility policy review, staff interview, physician interview and nurse practitioner (NP) interview, the facility failed to timely identify and provide adequate and necessary care for Resident #100, who experienced an acute change in condition. This resulted in Immediate Jeopardy and actual harm/serious health outcomes and potential for death beginning on 06/20/24 when the facility failed to recognize and adequately and timely respond to a decline in Resident #100's condition. Beginning on 06/20/24, Resident #100 was observed to have difficulty swallowing and his diet was downgraded to pureed. The physician was not notified of this change in condition. [...]

Inspectors wroteBased on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure a shared blood glucose meter (glucometer) was cleaned and disinfected between use with residents. This affected three (#31, #8, and #63) of three residents observed for blood sugar assessment with use of a glucometer. This had the potential to affect two (#30 and #74) additional residents who received blood sugar checks via glucometer. The facility census was 95.

Inspectors wroteBased on observations, resident interview, staff interview, medical record review and review of a local police department (LPD) report, the facility failed to ensure timely and appropriate toileting and incontinence care was provided. This affected three (Residents #80, #98, and #95) of four residents reviewed for incontinence care. The facility census was 95.

Inspectors wroteBased on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected two (#6 and #8) of three residents reviewed for medication administration. The facility census was 95.

Inspectors wroteBased on observation, record review, and interview, the facility failed to securely administer medications according to professional standards. This affected four (Resident #78, #18, #54, and #84) of seven residents reviewed for medication administration. The total census was 93.

Inspectors wroteBased on observation, family interview, and staff interviews the facility failed to ensure phone calls were timely answered and addressed when transferred to nursing staff. This had the potential to affect all residents. The facility census was 81. Findings Include: Interview on 03/27/24 at 12:04 P.M. with Resident #42's daughter revealed when she calls the facility, she is transferred to the nurse's station. No staff answered her calls, so she leaves messages but never receives return calls. Observation on 03/27/24 at 12:44 P.M. revealed the facility's main phone number was called. Business Office Manager (BOM) #308, who had filled in as receptionist, answered and transferred the call to Resident #50's nursing station. At 12:48 P.M. BOM #308 came back on the line and transferred the call to a different station due to no answer. At 12:51 P.M. [...]

Inspectors wroteBased on observation, medical record review, resident interview, family interview, staff interview, and review of the facility policy, the facility failed to treat Resident #24 with dignity and respect during an interview. This affected one resident (#24) of three residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on medical record review, phone text review, resident interview, family interview, staff interview, review of the facility time sheets, and review of the policy, the facility failed to implement their abuse policy after allegations of staff-to-resident abuse. This affected one resident (#24) of three residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on medical record review, phone text review, resident interview, family interview, staff interview, and review of the policy, the facility failed to timely report an allegation of staff-to-resident abuse to the state agency. This affected one resident (#24) of three residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on medical record review, phone text review, resident interview, family interview, staff interview, and review of the policy, the facility failed to timely investigate an allegation of staff-to-resident abuse. This affected one resident (#24) of three residents reviewed for abuse. The facility census was 98.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #57 was consistently gotten out of bed. This affected one resident (#57) of three residents reviewed for activities of daily living provided for dependent residents. The Facility census was 81.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #57 was consistently provided with activities that met his needs. This affected one resident (#57) of three residents reviewed activities. The facility census was 81.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure timely notification to residents of changes to Medicaid coverage. This affected one (Resident #64) of three residents reviewed for Medicaid coverage. The total census was 70.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident blood lab draws for laboratory testing were completed as ordered by the physician. This affected one (Resident #64) of three residents reviewed for laboratory testing. The facility census was 70 residents.

Inspectors wroteBased on medical record review, staff interview, review of employee files, review of online resource per the Centers for Disease Control (CDC), and review of the facility policy, the facility failed to offer Coronavirus (COVID-19) vaccinations to residents and staff. This affected three (Resident #55, #31, and #71) of five residents reviewed for vaccine administration. The facility census was 70 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide showers as scheduled. This affected two residents (Resident #24 and Resident #47) of five residents reviewed for showers.