Avenue Care: Resident Discharged Without Documentation - OH
The incident at Avenue Care and Rehabilitation Center began when Resident #26 attempted to urinate in the common dining area while other residents ate dinner. Registered Nurse #799 tried to redirect him to his room, calling the common area inappropriate for urination.
The resident refused and started grabbing dinner plates from other residents who were eating. Multiple redirection attempts failed.
Resident #26 then walked toward the lobby, stating he needed to get to his car to work on it. RN #799 and a certified nurse aide followed, continuing attempts to redirect him to his room.
The resident tried to open the secured door to the main entrance. RN #799 held the door shut.
Resident #26 became more agitated and attempted to hit the nurse. A second nurse contacted Nurse Practitioner #811, who ordered transport to a local emergency room for evaluation.
At 7:15 PM, Resident #26 was transferred to the ER. His medical chart contained no further documentation about what happened after transport.
The Mobile Director of Nursing told inspectors on August 11 that Resident #26 had been admitted to the hospital. When discharged, he would transfer to another facility with a secured unit and would not return to Avenue Care.
But the Director of Nursing revealed a problematic interpretation of discharge procedures during her interview that same day at 5:10 PM. Anyone sent to the ER for evaluation was considered discharged, she said.
The DON couldn't explain why no further documentation existed in Resident #26's chart regarding what happened after his transfer. She couldn't provide discharge paperwork or information about where he went.
No immediate discharge documentation existed regarding Resident #26's inability to return to the facility.
The facility's own policy contradicted this practice. Avenue Care's "Discharge Planning & Managing Length of Stay" policy, dated December 1, 2022, required specific steps for resident discharges.
Discharge planning should involve identifying each resident's discharge goals and needs, implementing appropriate interventions, and regularly evaluating those interventions throughout the resident's stay, according to the policy.
When a facility anticipates discharge, a discharge summary including recapitulation history must be completed. A final discharge summary should be completed upon discharge and given to the resident or responsible party.
The summary must include medication reconciliation, discharge medication orders, and a post-discharge plan of care. The plan should specify where the resident will reside, any follow-up care appointments, and any post-discharge medical services.
None of this documentation existed for Resident #26.
The case illustrates how nursing homes can effectively discharge residents without following their own policies or federal requirements. By simply transporting someone to an emergency room and declaring them discharged, facilities can avoid the paperwork and planning that protects vulnerable residents.
Federal inspectors investigated the incident as part of two separate complaints filed against Avenue Care. The violation received a "minimal harm or potential for actual harm" rating affecting few residents.
But for Resident #26, the consequences were immediate. He went from being a nursing home resident receiving care to being transferred between facilities without proper discharge planning or documentation of his needs.
The facility's interpretation that ER transport equals automatic discharge creates a dangerous precedent. Residents experiencing behavioral health crises could be sent away without the comprehensive discharge planning designed to ensure continuity of care.
Avenue Care administrators couldn't explain where Resident #26 went after leaving their facility. They couldn't provide documentation of his transfer to the secured unit mentioned by the Mobile Director of Nursing.
The resident who tried to work on his car in the lobby disappeared from the facility's records the moment he entered the ambulance.
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.
The incident at Avenue Care and Rehabilitation Center began when Resident #26 attempted to urinate in the common dining area while other residents ate dinner.
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.