Avenue Care: Family Left in Dark on 7 Hospitalizations - OH
Resident #6, who suffers from end-stage renal disease and diabetes, was hospitalized on February 14, returned February 19, then sent back to the hospital February 26. The family heard nothing.
She went to the hospital from dialysis on March 5. No call home.
On March 13, she was hospitalized from a doctor's office visit, then sent out again the same day at 1:22 a.m. and returned at 4:49 a.m. The family remained in the dark about both trips.
Two days later, on March 15, she was ordered to the hospital again. Still no family notification. She was readmitted March 21.
Unit Manager Licensed Practical Nurse #745 confirmed to inspectors on August 13 that there was no documentation showing the resident's family was ever notified about any of the seven hospital transfers between February and March.
The facility's own policy, dated July 28, 2022, requires staff to "promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition." The policy specifically states its purpose is ensuring timely care when residents experience changes "that had or was likely to cause adverse negative health outcomes."
Federal regulations mandate that nursing homes immediately tell residents, their doctors, and family members about situations that affect the resident, including injuries, medical decline, or room changes. The requirement exists because family members often serve as crucial advocates for residents who may be unable to speak for themselves due to illness or cognitive impairment.
For Resident #6, whose complex medical conditions included gastrointestinal hemorrhage and heart rhythm problems in addition to kidney failure and diabetes, the repeated hospitalizations suggested serious ongoing health issues. Her family remained unaware as she moved between the nursing home, dialysis center, doctor's office, and hospital emergency department.
The inspection, conducted in response to a complaint filed as OH00163811, reviewed two residents for change-in-condition notifications. Only Resident #6 was affected by the violation. The facility housed 87 residents at the time of the inspection.
Electronic medical records showed detailed nurse notes documenting each hospital transfer, including specific times and circumstances. A February 14 note at 6:57 p.m. recorded that Resident #6 was "ordered to be sent to the hospital." A March 5 note at 4:04 p.m. documented she was "sent to the hospital from dialysis." A March 13 physician note recorded she "went to the hospital from the doctor's office."
But nowhere in the extensive documentation did inspectors find evidence that anyone picked up the phone to call her family.
The failure to communicate stretched across different shifts and circumstances. Whether Resident #6 was sent to the hospital during regular business hours or in the middle of the night, whether she left from the nursing home, dialysis center, or doctor's office, the result was the same: her family heard nothing.
The March 13 sequence was particularly striking. After being hospitalized from the doctor's office during the day, Resident #6 was sent out again at 1:22 a.m., returning less than four hours later at 4:49 a.m. The rapid turnaround suggested an emergency situation, yet her family remained uninformed about both the crisis and her safe return.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But for the family of Resident #6, the impact was likely far more significant. They missed opportunities to advocate for their loved one, provide comfort during medical crises, and make informed decisions about her care.
The complaint that triggered the inspection suggests someone – possibly family members who eventually learned about the communication breakdown – was concerned enough about the facility's practices to contact state regulators.
Resident #6's medical complexity made family communication especially important. End-stage renal disease requires careful monitoring and frequent medical interventions. Combined with diabetes, heart problems, and gastrointestinal issues, her condition demanded the kind of vigilant oversight that engaged family members often provide.
Instead, her family spent five weeks unaware that their loved one was cycling between medical facilities, experiencing repeated health crises serious enough to require emergency hospitalization.
The nursing home's policy promised prompt notification to responsible parties. The reality was seven hospitalizations in silence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue Care and Rehabilitation Center, The from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVENUE CARE AND REHABILITATION CENTER, THE in WARRENSVILLE HEIGHTS, OH was cited for violations during a health inspection on August 13, 2025.
She went to the hospital from dialysis on March 5.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.