Health inspection·February 1, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #64 revealed an admission date of [DATE] with diagnoses including cerebral infarction, diabetes, and chronic obstructive pulmonary disorder. Review of the census records for the facility revealed Resident #64's payor source was Medicaid from admission on [DATE] to [DATE]. Resident's payor source on [DATE] was private pay. Review of the October Medicaid eligibility form for Resident #64 revealed the resident's Medicaid coverage expired on [DATE]. Review of an email communication dated [DATE] from the facility and the county Medicaid agency regarding Resident #64 revealed the facility requested urgent attention to the resident's Medicaid renewal application. Further review of the email from the facility revealed Resident #64's Medicaid coverage terminated [DATE] and the lack of coverage was a financial hardship to the resident. Interview on [DATE] at 9:51 A.M. with Resident #64 confirmed she lost her Medicaid coverage and did not know why. She said the facility was working with the county Medicaid agency to obtain retroactive coverage so she didn't have to pay out of pocket, but she felt the lapse should not have happened. Resident #64 further confirmed she had to miss therapy and some outside appointments due to the lack of Medicaid coverage and the facility had not notified her of changes to her Medicaid coverage prior to termination. Interview on [DATE] at 11:06 A.M with Social Services Designee (SSD) #302 confirmed the facility Business Office Manager (BOM) completed renewal applications for residents on Medicaid. SSD #302 confirmed the facility was not aware Resident #64's Medicaid coverage was terminated until [DATE]. Interview on [DATE] at 3:36 P.M. with BOM #303 confirmed she had been employed with the facility for about a week. BOM #303 confirmed the facility had requested a state hearing to place Resident #64 back on Medicaid. BOM #303 believed Resident #64's Medicaid coverage was probably terminated due to a missed renewal notice. Page 1 of 5 366495 366495 02/01/2024 Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144

F 0582 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 5:13 P.M. with the Administrator and the Director of Nursing (DON) confirmed the facility had no documentation of notification to Resident #64 that her Medicaid coverage had been terminated [DATE]. This deficiency represents non-compliance investigated under Complaint Number OH00150308. Residents Affected - Few 366495 Page 2 of 5 366495 02/01/2024 Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #64 revealed an admission date of 08/17/23 with diagnoses including cerebral infarction, diabetes, and chronic obstructive pulmonary disorder. Review of physician's orders for Resident #64 revealed an order dated 11/27/23 to obtain a complete blood count (CBC) and basic metabolic panel (BMP) to be drawn weekly for three weeks. Review of the laboratory test results for Resident #64 revealed they did not include the weekly CBC and BMP laboratory tests for the resident as ordered on 11/27/23. Interview on 01/30/24 at 5:13 P.M. with the Director of Nursing (DON) and the Administrator confirmed the facility had not obtained the CBC and BMP laboratory tests for Resident #64 as the physician had ordered. This deficiency represents non-compliance investigated under Complaint Number OH00150308. 366495 Page 3 of 5 366495 02/01/2024 Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based 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. Findings include: 1.Review of the medical record for Resident #31 revealed an admission date of 10/25/23 with diagnoses including sepsis, diabetes, and altered mental status. Review of the vaccination record for Resident #31 revealed it did not include documentation that a COVID-19 vaccine was offered at the facility or previously administered. The record revealed Resident #31 was overdue for a COVID-19 vaccine as of 01/08/21. Review of the medical record for Resident #55 revealed an admission date of 11/15/23 with diagnoses including sepsis, diabetes, and altered mental status. Review of the vaccination record for Resident #55 revealed the resident had received COVID-19 vaccines on 04/15/21 and 05/06/21 and there was no documentation indicating the resident was offered an updated COVID-19 vaccination. Review of the medical record for Resident #71 revealed an admission date of 06/02/23 with diagnoses including respiratory failure, chronic obstructive pulmonary disorder, and end stage renal disease. Review of the vaccination record for Resident #71 revealed the resident had received COVID-19 vaccines on 07/14/21 and 08/05/21 and there was no documentation indicating the resident was offered an updated COVID-19 vaccination. Interview on 01/31/24 at 5:40 P.M. with the Administrator confirmed Residents #31 #55, #71 were not up-to date with COVID-19 vaccines and the facility had no documentation indicating the residents were offered updated COVID-19 vaccination. Interview on 02/01/24 at 10:20 A.M with Interim Infection Control Director (IICD) #602 confirmed residents should be screened for vaccine eligibility on admission, and that COVID-19 vaccination was considered up to date if last given in 2023 or 2024. IICD #602 confirmed residents should be offered COVID-19 vaccination if eligible. 2. Review of the employee files for Registered Nurse (RN) #201, Licensed Practical Nurse (LPN) #401, and State Tested Nursing Assistant (STNA) #402 revealed the files did not include documentation indicating staff were offered COVID-19 vaccines and education regarding the risks and benefits of COVID-19 vaccination. Interview on 01/31/24 at 10:52 A.M. with State Tested Nursing Assistant (STNA) #402 confirmed she 366495 Page 4 of 5 366495 02/01/2024 Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144

F 0887 Level of Harm - Minimal harm or potential for actual harm was hired a few months ago and the facility had not offered her a COVID-19 vaccine nor educated her regarding the risks and benefits of COVID-19 vaccination. Interview on 01/31/24 at 1:15 P.M. with the Administrator and the Director of Nursing (DON) confirmed the facility did not offer COVID-19 vaccines to employees. Residents Affected - Few Interview on 02/01/24 at 10:42 A.M. with Human Resources Director (HRD) #601 confirmed the facility requested staff bring COVID-19 vaccination information to orientation upon being hired. HRD #601 confirmed the nursing department was responsible for vaccinations. HRD #601 confirmed the employee files for RN #201, LPN #401, and STNA #402 did not include information regarding COVID-19 vaccines provided to staff nor did they include education regarding the risks and benefits of COVID-19 vaccination. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#ftnote retrieved on 02/09/24 revealed everyone aged 5 years and older should get one dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. None of the updated 2023-2024 COVID-19 vaccines was preferred over another. Review of the facility policy titled COVID vaccination revised 01/02/24 revealed the CDC recommended residents receive the 2023-2024 updated COVID vaccine, and the facility should ensure residents could receive the vaccine. This deficiency represents non-compliance investigated under Complaint Numbers OH00150308 and OH00149877. 366495 Page 5 of 5