Avenue Care: UTI Antibiotic Delayed 4 Days - OH
Resident 102 at Avenue Care and Rehabilitation Center was supposed to start taking Fosfomycin tromethamine on Friday, June 13, after laboratory results confirmed a UTI two days earlier. The antibiotic wasn't in stock.
Staff marked the medication administration record with "See nurse notes" on both Friday, June 13 and Sunday, June 15. The resident finally received the first dose on Tuesday, June 17.
The 87-bed facility admitted Resident 102 on May 1 with cellulitis of the left lower limb, leg pain, anxiety disorder, and glaucoma. The resident had intact cognition and required supervision for dressing and mobility, using both a walker and wheelchair. They were occasionally incontinent.
On June 7, physicians ordered a urine analysis for possible UTI. The sample was collected that evening and received by the laboratory on June 10.
Laboratory results on June 12 confirmed the UTI and provided antibiotic recommendations. That same day at 3:17 p.m., nurses documented educating Resident 102 about the new antibiotic order, telling them "the medication would be in that night."
It wasn't.
The physician had ordered Fosfomycin tromethamine 3 grams to be given by mouth every Tuesday, Friday, and Sunday for three doses, starting June 13 at 7:00 a.m. The facility also prescribed Pyridium to treat UTI symptoms twice daily for two days.
But when Friday arrived, the antibiotic wasn't available. Nurse's notes from Sunday, June 15 at 12:07 p.m. confirmed "Fosfomycin tromethamine 3 gm oral packet was not available."
Assistant Director of Nursing 704 caught the problem on Monday, June 16. She contacted the nurse practitioner, had the medication reordered, and ensured the first dose was finally given on Tuesday, June 17.
During the August inspection, ADON 704 confirmed to federal investigators that the medication "was not available" on the scheduled Friday and Sunday doses. The Director of Nursing verified the antibiotic wasn't given until June 17.
The original antibiotic order was discontinued on June 16 and reordered the same day to start June 17.
Resident 102 discharged against medical advice to an independent living facility on July 22, about five weeks after the medication delay.
The medication error occurred despite federal requirements that nursing homes ensure residents are free from significant medication errors. Facilities must maintain adequate pharmaceutical supplies to meet residents' needs as prescribed by their physicians.
UTIs in nursing home residents require prompt treatment to prevent complications including kidney infections, sepsis, and increased confusion in elderly patients. Delayed antibiotic treatment can allow bacterial infections to worsen and spread.
The inspection was conducted in response to multiple complaints filed against Avenue Care. Federal investigators cited the facility for failing to ensure proper medication administration, affecting one of two residents they reviewed for urinary tract infections.
Avenue Care's medication management failure left Resident 102 waiting four days for treatment while suffering from a confirmed bacterial infection. The resident had been told on June 12 that medication would arrive "that night" but didn't receive the prescribed antibiotic until nearly a week later.
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 antibiotic wasn't in stock.
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.