Avenue Care: Two-Day Delay Reporting Infection - OH
The breakdown in communication at Avenue Care and Rehabilitation Center involved Resident #59, who required mechanical lift assistance and help from two staff members for transfers. Laboratory results showing his urine culture tested positive for infection were reported on December 1, but his physician wasn't notified until December 3.
Director of Nursing couldn't explain the delay.
"Resident #59's physician should have been notified as soon as possible after his urine culture results were reported by the laboratory," the Director of Nursing told inspectors during an August interview. She confirmed the two-day gap but said she "did not know why there was a two day delay for Resident #59's urine culture results to be reported to the physician, and there should have been a progress note about it."
The facility's own policy required immediate physician notification. The Resident Change in Condition policy, dated July 28, 2022, stated the facility "would promptly notify the resident, his or her attending physician and responsible party of changes in the resident's condition." Licensed nurses were expected to "take immediate action to ensure timely and appropriate care and services were met when a resident change in condition was identified."
But the policy wasn't followed.
Nurse Practitioner #801, who treated the resident, said she expected urine specimens to be collected within 48 hours of ordering them. When asked about the case during her August interview, she indicated frustration with the facility's specimen collection process.
"If she ordered Resident #59's urine specimen for urinalysis and culture and sensitivity twice it was probably because she was frustrated that she had not received the report and ordered it again," according to the inspection report. The nurse practitioner "could not remember the details because it was awhile ago."
The confusion extended beyond the reporting delay. On December 3 — the same day the physician was finally notified — staff collected another urine specimen from Resident #59. The Director of Nursing "confirmed Resident #59 had a urine specimen for urinalysis and culture and sensitivity collected on 12/03/25 and there was no order in his record or progress note regarding the urine specimen."
She couldn't explain why that second specimen was collected.
The facility also failed to follow through on earlier orders. In November, a urine test was ordered for Resident #59, but "there was no evidence the urine was collected and sent to the laboratory," the Director of Nursing confirmed.
Nurse Practitioner #801 told inspectors she "did not know there was a delay of two days for reporting Resident #59's urine culture results." She said she "hoped a member of the physician team would have been called with the results and would have responded on 12/01/25 with an antibiotic order if they felt it was appropriate."
The delay troubled her.
"She would have wanted to treat Resident #59's infection as soon as possible and did not have an explanation for the two delay from 12/01/25 through 12/03/25," according to the inspection report.
Urinary tract infections in nursing home residents can escalate quickly, particularly among wheelchair users and residents requiring mechanical lift assistance like Resident #59. The facility's policy acknowledged this urgency, stating that appropriate treatment should be delivered "to best manage a resident's change in condition and the effort to treat a residents physical or emotional status such as an illness or injury based on the outcome of severity during assessment."
Federal inspectors found the facility failed to meet this standard. The violation represented "minimal harm or potential for actual harm" affecting few residents, but highlighted systemic communication breakdowns between laboratory services, nursing staff, and physicians.
The inspection was conducted in response to a complaint filed with state health officials. Resident #59 required assistance with bathing and bed mobility in addition to his transfer needs, making prompt medical attention particularly important for preventing complications from untreated infections.
The two-day reporting delay meant Resident #59 potentially went without antibiotic treatment during a critical window when early intervention could have prevented the infection from worsening or spreading.
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.
Laboratory results showing his urine culture tested positive for infection were reported on December 1, but his physician wasn't notified until December 3.
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.