Avenue Care: Resident Fed While Lying Down - OH
The incident occurred on August 5th at Avenue Care and Rehabilitation Center when federal inspectors observed the morning meal routine for Resident #25, who required assistance with eating due to dysphagia, a condition that makes swallowing difficult and can lead to choking or aspiration pneumonia.
Certified Nurse Aide #772 entered the room carrying the meal tray and set it up next to the resident's bed. Without raising the bed height, she began feeding Resident #25 while standing and while the head of the bed remained at approximately 30 degrees.
Food immediately dropped onto the resident's gown. The aide continued feeding her anyway.
Only after several minutes did CNA #772 raise the head of the bed to about 90 degrees, the safer position for someone with swallowing difficulties. She continued standing throughout the feeding process.
When questioned by inspectors, the aide confirmed she always stood while feeding Resident #25 in her room and acknowledged dropping food on the resident's gown. She said when the resident ate in the dining room, she would sit while assisting her.
Licensed Practical Nurse #733 told inspectors that Resident #25 required assistance with feeding and explained the facility's inconsistent approach to meal locations. If nursing aides had enough time, they would help the resident out of bed into her wheelchair and take her to the dining room to eat. Otherwise, she was fed in her room.
The resident's care plan specified she needed dependent assistance from one staff member for eating and was dependent on staff for incontinence care. Her activities of daily living needs were to be met by staff while allowing her to participate as able.
Federal regulations require facilities to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of quality of life. The facility's own policy, dated October 3, 2023, states it must protect and promote residents' rights and recognize each resident's individuality.
Feeding residents with dysphagia at improper angles significantly increases aspiration risk. When food or liquid enters the airway instead of the esophagus, it can cause pneumonia or choking. The 30-degree angle observed by inspectors is far below the recommended 90-degree upright position for safe swallowing.
The standing position while feeding also presents problems. Caregivers cannot maintain proper eye contact or gauge the resident's comfort and swallowing ability when towering over them from above.
This violation was documented as part of three separate complaint investigations numbered OH00167217, OH00164532, and OH00162468, suggesting multiple concerns prompted the August inspection.
The deficiency was classified as causing minimal harm or potential for actual harm to few residents. However, for Resident #25, the daily reality meant lying nearly flat while food dropped onto her clothing as staff rushed through feeding assistance.
The facility must now submit a plan of correction explaining how it will ensure proper positioning during meals and adequate training for staff who assist residents with eating difficulties.
For residents like #25, who depend entirely on staff for basic needs like eating, the difference between sitting up properly and lying flat could determine whether their next meal ends in their stomach or their lungs.
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 21, 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.
Certified Nurse Aide #772 entered the room carrying the meal tray and set it up next to the resident's bed.
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.