Avenue at Brooklyn

In the surveyor’s words

From the most serious findings on record at Avenue at Brooklyn, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 2, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF678Aug 6, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF684Aug 6, 2024

  Based 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. […]

• Actual harm, isolatedF689Jul 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Jul 30, 2026

  Based 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. Findings include: 1. Review of the Payroll Based Journal report revealed the facility had a one-star staffing rating and was identified with low weekend staffing for the second fiscal year quarter from 01/01/26 through 03/31/26. Interviews with residents during the survey revealed they had concerns with staffing. […]