Health inspection·February 6, 2025

F 0685 Assist a resident in gaining access to vision and hearing services. 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 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. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an initial admission date of 10/23/23. Diagnoses included type I diabetes mellitus with ketoacidosis without coma, type I diabetes mellitus with diabetic autonomic (poly) neuropathy, type I diabetes mellitus with diabetic retinopathy without macular edema, type I diabetes mellitus with diabetic neuropathy, type I diabetes mellitus with diabetic chronic kidney disease, type I diabetes mellitus with hyperglycemia, type I diabetes mellitus with hypoglycemia without coma, chronic pancreatitis, hypotension, cardiomegaly, dependence on renal dialysis, end stage renal disease, and epilepsy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition and was independent with activities of daily living (ADLs). Review of the social service note dated 10/24/24 at 12:11 P.M. revealed seen by audiology and referred to ENT. Further review of the progress notes was silent regarding any information related to the referral or Resident #12 seeing ENT. Review of the audiology visit note dated 10/24/24 at 12:50 P.M. revealed the reason for the visit was for a hearing exam. Under assessment and plan audiology recommend ear, nose, and throat (ENT) consult due to asymmetrical hearing loss, tinnitus and dizziness. Recommendations discussed with Social Services Director (SSD) #312, she will have this scheduled. Interview on 02/03/25 at 11:38 A.M. to with Resident #12 revealed she had seen the audiologist awhile ago and there was a referral to see ENT. Resident #12 stated there was no appointment made for her to see ENT. Interview on 02/05/25 at 3:47 P.M. with SSD #312 revealed Resident #12 had seen the audiologist on 10/24/24 and there was a referral for the ENT. SSD #312 stated that it was sent to the nurse, but she was not sure what nurse she gave it to to make the appointment. SSD #312 stated it would have been whoever was working that day. Interview on 02/05/25 at 5:25 P.M. with the Director of Nursing (DON) revealed the ENT referral was brought to her attention today but she was not sure what happened since the referral was made prior to her starting at the facility. DON stated she told the nurse to get it scheduled today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an initial admission date of 10/23/23. Diagnoses included type I diabetes mellitus with ketoacidosis without coma, type I diabetes mellitus with diabetic autonomic (poly) neuropathy, type I diabetes mellitus with diabetic retinopathy without macular edema, type I diabetes mellitus with diabetic neuropathy, type I diabetes mellitus with diabetic chronic kidney disease, type I diabetes mellitus with hyperglycemia, type I diabetes mellitus with hypoglycemia without coma, chronic pancreatitis, hypotension, cardiomegaly, dependence on renal dialysis, end stage renal disease, and epilepsy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition, was independent with activities of daily living (ADLs), and received dialysis. Review of the physician orders for February 2025 revealed active orders to ensure resident has a dialysis binder for transport and dialysis monitoring forms completed every day shift every Monday, Wednesday, and Friday with a start date of 12/06/24. Review of the dialysis communication monitoring forms revealed completed forms for 11/26/24, 11/29/24, 12/02/24, 12/05/24, 12/09/24, 12/18/24, and 12/20/24. There were no communication forms for the months of January 2025 or February 2025. Interview on 02/05/25 at 2:44 P.M. with Director of Nursing (DON) verified the facility did not have all the communication forms between the facility and dialysis. The DON verified they were deficient in this area. Reviewed policy Dialysis Monitoring, revised December 2022 revealed the facility will maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, PTSD and irritable bowel syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was severely cognitively impaired and was independent for completing activities of daily living (ADLs). 2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, PTSD and dementia. Review of the most recent MDS assessment dated [DATE] revealed Resident #43 was severely cognitively impaired and required supervision from facility staff for completing ADLs. 3. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, PTSD and anxiety disorder. Review of the most recent MDS assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired and required hands on assistance of one staff person for completing her ADL's. 4. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, PTSD and anxiety disorder. Review of the most recent MDS assessment dated [DATE] revealed Resident #98 was cognitively intact and required hands on assistance of one staff person for completing ADL's. 5. Review of the medical record revealed Resident #303 was admitted to the facility on [DATE] with diagnoses that included psychosis, PTSD and dementia. Review of the most recent MDS assessment dated [DATE] revealed Resident #303 was moderately cognitively impaired and was independent for completing ADL's. Review of the electronic medical record and hard (paper) charts revealed no assessment, care plan or any other documentation related to Residents #8, #43, #80, #98 and #303's trauma diagnosis or culturally competent care. Interview with Regional Director (RD) #950 on 02/04/25 at 1:45 P.M. verified the facility had no evidence of any documentation related to Residents #8, #43, #80, #98 and #303's PTSD diagnoses. Review of the policy entitled Trauma Informed Care dated 10/04/22 revealed the facility will complete an assessment to identify residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post traumatic stress disorder. The policy further revealed the facility engage in Care Planning to Address Cultural Preferences Resident-specific approaches must be developed and included in the resident' care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review of Resident #22 revealed he was admitted [DATE] and had diagnoses including cerebral infarction, hemiplegia and hemiparesis, human immunodeficiency virus (HIV) disease, aphasia, and neurogenic bowels. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 as being occasionally incontinent and requiring substantial assistance for toileting. Interview with Resident #22 on 02/03/25 at 9:11 A.M. revealed he sometimes waited 30 minutes for attention when ringing his call light and was occasionally incontinent. Observation on 02/04/25 at 1:27 P.M. revealed Resident #22's call light was on. Interview with the resident at this time revealed he was waiting for incontinence care. Continuous observation of Resident #22's room revealed Licensed Practical Nurse (LPN) #305 answered the call light on 02/04/25 at 1:33 P.M. LPN #305 said Resident #22's aide was giving a shower to another resident and she would try to get someone else to provide incontinence care. Observation revealed Admissions Director #307 entered Resident #22's room on 02/05/25 at 1:58 P.M., and Certified Nurse Aide (CNA) #422 entered the room on 02/05/25 at 2:05 P.M. both spoke with the resident then left without providing incontinence care. Observation revealed CNA #350 and CNA #422 entered Resident #22's room to provide incontinence care on 02/04/25 at 2:20 P.M. Observation of the subsequent incontinence care revealed the resident had a heavily wettened brief with no clear evidence of moisture-related skin damage. Interview with CNA #350 on 02/04/25 at 2:35 P.M. confirmed it had taken at least 53 minutes after the resident called for assistance for Resident #22 to receive incontinence care. CNA #350 said she was covering over 20 residents including Resident #22. She felt the staff was a very good team and someone usually would have given the care while she giving a shower, however today they were working short with only four aides assigned to give care throughout the building, with one unavailable due to the need to have a fire watch. This deficiency represents noncompliance investigated under Master Complaint Number OH00162372 and OH00161503. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: Observation of medication administration for Resident #25 by Licensed Practical Nurse (LPN) #426 on 02/03/25 at 8:47 A.M. revealed one pill of magnesium oxide 400 milligrams (mg), one pill of cranberry 450 mg, one pill of vitamin D-3 125 micrograms, and two pills of simethicone (gas relief) 80 mg were prepared for, handed to and consumed by Resident #25. Record review of Resident #25 revealed they were admitted [DATE] and had diagnoses including femur fracture, major depressive disorder, dementia, and gastric ulcer. Resident #25 had no order for magnesium oxide 400 mg, and instead had an active order dated 07/31/24 for 500 mg magnesium oxide to be given daily. Resident #25 also had active orders dated 07/31/24 for vitamin D-3 pills, cranberry pills, and Gas-X (a brand name for simethicone) capsules, all of which did not identify the correct dose to give to the resident. Interview with LPN #426 at 2:08 P.M. on 02/03/25 confirmed Resident #25 had no order for magnesium oxide 400 mg, and instead had an active order dated 07/31/24 for 500 mg magnesium oxide to be given daily. LPN #426 also confirmed the active orders for vitamin D-3, cranberry, and Gas-X did not contain a prescribed dose and that the medications were administered in error. These findings revealed four errors out of 29 observed opportunities for medication error, creating an error rate of 13.8%. Record review of the facility's medication administration policy dated 08/2014 revealed the five rights of medication administration were to be used, including a check for appropriate dosage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings include: Observations during initial tour of the kitchen on 02/03/25 between 9:42 A.M. and 10:06 A.M. with Mobile Dietary Manager (MDM) #450 revealed: • Dry storage area under the rack against wall had a large container of cooking oil, on the floor underneath was a large oil spill. • Observed various food debris on top of the oven, an oven mitt on the floor behind and between the oven and steamer. • The deep fryer had various food crumbs on it, an old french fry in one of the baskets, the outside of the deep fryer had grease stains running down. • The floor under the steamer and deep fryer had a brownish substance and food crumbs • The two set of shelves under the steam stable facing the stove area had various crumbs/food debris. On these shelves were clean steam table pans. • The reach-in freezer under the steam table observed various food debris and loose • The reach-in refrigerator under the steam table observed a sliced tomato and lettuce leaf wrapped in saran not dated or labeled. • The side of the steam table facing the entrance into the kitchen shelves had various crumbs/food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 debris. On the shelves were clean cups and bowls. There was also a container holding the built-up utensils that had various food debris and food stains. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Many Observed an unattached tubing for the fruit punch of the juice/pop machine was on the floor. • The ice machine had moderate amount of dried whitish substance on the outside of it. • The reach-in refrigerator near the juice/pop machine had a small amount of standing water in the inside. There was various food splatter on the top of door to the freezer portion of the refrigerator and the outside both doors. Interview on 02/03/25 between 9:42 A.M. and 10:06 A.M., MDM #450 verified all of the findings and stated the whitish substance on the ice machine looked like lime buildup. Observation on 02/05/25 at 9:30 A.M. of the front hall nursing unit refrigerator with MDM #450 revealed a dried reddish substance on the bottom of the freezer and running down the inside door of the freezer. At this time MDM #450 verified the observation. Reviewed policy General Sanitation of the Kitchen, undated revealed food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Many Findings include: Observation on 02/05/25 at 10:06 A.M. of the outside dumpsters revealed two dumpsters, both with the lids opened. There was a large clear trash bag of trash on the ground next to the dumpster closer to the door to the building. Observed on the ground around and between the dumpsters was a moderate amount of various trash including an empty cigarette package, several used latex gloves, etc. Interview on 02/05/25 at 10:08 A.M. with Mobile Dietary Manager (MDM) #450 verified the observation. MDM #450 stated maintenance was responsible for maintaining the dumpster area. Reviewed policy Trash Handling, undated revealed outside dumpsters and surrounding area are to be kept clean and [NAME] of debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Many Findings include: Review of the facility's admission packet revealed its arbitration agreement and requirements were contained on pages nine and ten of the facilities admission agreement that authorized the facility to provided care and services required to be admitted to the facility. Review of the facility's arbitration agreement revealed that the agreement does not state that the resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman. Interview with Corporate Nurse (CN) #999 on 02/05/25 at 10:25 A.M. verified the agreement does not state that the resident or resident representative may communicate with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman and it should. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Many Findings include: Review of the facility's admission packet revealed that an arbitration agreement was within the packet and located on pages nine and ten within the general admission agreement required for admission/treatment from the facility. Review of resident medical records during the survey revealed admission agreements and subsequently arbitration agreements were signed by all residents residing in the facility. Review of the Who Will Conduct Arbitration subsection of the arbitration agreement revealed C. The arbitration shall be conducted by the National Arbitration Forum (NAF). Information regarding NAF and a copy of pertinent rules and forms may be located at NAF's website, www. arbitration-forum. com; by contacting NAF toll-free at [PHONE NUMBER], by toll-free fax at [PHONE NUMBER]; or at P.O. Box 50191, Minneapolis, MN 55405. The agreement does not allow the resident or resident representative to seek other counsel except American Arbitrators Association (AAA) for binding arbitration disputes. Further review of the arbitration agreement revealed no discussion of a neutral venue to be agreed upon by all parties during the process Interview Corporate Nurse (CN) #999 on 02/05/25 at 10:25 verified the agreement did not contain information related to a neutrally agreed upon arbitrator or information regarding a neutral venue for all proceedings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366495 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Brooklyn 4700 Idlewood Drive Brooklyn, OH 44144 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based 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. Findings include: Review of the medical record for Resident #63 revealed an admission date of 12/15/23. Diagnoses included stroke affecting left side and pneumonia. The Resident #63 was admitted to hospice services on 10/07/24. Interview on 02/05/25 at 12:49 P.M. with Resident #63's power of attorney (POA) revealed the POA complained of a lack of communication between the facility and hospice services. The POA stated the facility did not provide a designated staff member to address Resident #63's medical care. The POA stated she was not provided updates on hospice services or Residents #63's medical care. Review of the Resident #63's hospice contract revealed the agreement did not specify a designated staff member, a hospice representative, and/or the medical director information for coordination of care and communication between the hospice provider and the facility. Interview on 02/05/25 at 4:11 P.M. of the Regional Nurse #316 confirmed the hospice contract did not specify a designated staff member or hospice representative. The Regional Nurse #316 verified the hospice physician/medical director information was not provided in the agreement. Review of the hospice agreement revealed the resident and/or guardian has the right to know who the caregivers are involved in care, their professional titles and their role; the right to effective verbal and written communication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366495 If continuation sheet Page 12 of 12