Avenue at Lyndhurst: CNA Left Paralyzed Patient Alone - OH
CNA #331 told inspectors at Avenue at Lyndhurst she was doing check and change rounds early that morning when she turned Resident #39 onto her right side during personal care. The resident had no bed rail on the right side to hold onto.
The aide said she left the room to get washcloths from the bathroom sink. When she returned, Resident #39 was already falling out of bed.
But her story kept changing.
RN #306, who worked the night shift, said CNA #331 came to her reporting the fall. The nurse told inspectors on August 26 that the aide "had changed her story of what happened several times and the way Resident #39 fell was not making sense."
When the nurse questioned Resident #39 directly, the paralyzed woman reported that CNA #331 had left her turned on her side when she fell.
The nursing assistant later admitted to inspectors that having two people in the room would have been "more appropriate" while changing Resident #39, who was completely dependent on staff for care due to quadriplegia. RN #306 confirmed the resident "should not have been turned onto her right side and left without support."
The incident reflects broader problems with fall investigations at the facility. In another case involving Resident #99, staff documentation contradicted itself about whether a fall was witnessed.
On March 4, Resident #99 was returning from a radiation therapy appointment when she fell on the walkway outside the building. The resident had been admitted February 13 with diagnoses including pneumonia, malignant neoplasm of the esophagus, encephalopathy, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder.
A nurse's note stated the fall was witnessed by both the receptionist and the person transporting the resident. But the formal fall investigation dated the same day claimed the fall was "unwitnessed."
Resident #99 sustained a right index finger skin tear, minor right knee scrape, and minor left pinky finger scrape. She rated her pain as three on a scale of zero to ten. Vital signs were taken and she had no head injuries.
However, staff failed to complete required documentation. The pain assessment form and fall assessment form were never filled out, according to RDCS #502, who verified the missing paperwork during an August 22 interview with inspectors.
The resident's assessment showed she had intact cognition and was not considered at risk for falls. She required supervision or touching assistance for sit-to-stand transfers, moving from chair to bed, and walking. Her medications included antipsychotic drugs given only as needed, plus antianxiety, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medications.
Both incidents were part of a complaint investigation that included five other complaint numbers spanning multiple safety concerns at the 5442 Rae Road facility.
For Resident #39, the consequences of being left alone while paralyzed and positioned on her side without support meant falling out of bed while unable to catch herself or call for help. The aide's shifting explanations suggest awareness that leaving a quadriplegic resident unattended during personal care violated basic safety protocols.
CNA #331 told inspectors she checked on Resident #39 after finding her falling and "got her into a comfortable position" before seeking help from the nurse. But the damage was already done to a resident who depended entirely on staff to keep her safe during the most vulnerable moments of daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue At Lyndhurst from 2025-08-28 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 AT LYNDHURST in LYNDHURST, OH was cited for violations during a health inspection on August 28, 2025.
The resident had no bed rail on the right side to hold onto.
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.