Avenue at Lyndhurst: Transfer Notice Failures - OH
That was one of three residents at Avenue at Lyndhurst whose hospitalizations were never reported to the Long-Term Care Ombudsman, the independent advocate residents can call when something goes wrong. Inspectors documented the failures during a complaint investigation completed August 28, 2025. Every resident reviewed for hospitalization had a problem. Three for three.
The Social Service Designee, identified in the report only as SSD #388, confirmed the failures directly. In an interview with inspectors, she said the Ombudsman was not notified when Resident #10 was transferred to the hospital. She said the same about Resident #93. There was no ambiguity about what happened. Nobody called.
Resident #93's situation was worse by volume. She had been admitted with diabetes, general anxiety disorder, and acute respiratory failure, and she was sent to the hospital not once but three times: on dates the facility redacted, then again on May 28, 2025, and again on July 1, 2025. Inspectors checked both the electronic chart and the paper chart. There was no documented evidence the Ombudsman was notified of any of those three hospitalizations. SSD #388 confirmed it: none of the transfers were reported. Resident #93 was eventually discharged from the facility on July 25, 2025.
The third resident, #98, had been living at the facility since February 2024 with a medical history that included stroke, pneumonia, hemiplegia, sepsis, a gastrostomy tube, and dementia. An assessment from August 2024 documented that she had severely impaired cognition and needed maximum assistance with eating, oral hygiene, dressing, personal hygiene, and bathing. She required help with nearly everything.
She was hospitalized on June 17, 2024, and again on August 8, 2024. No transfer notices were issued for either hospitalization. The Corporate Director of Operations, identified as #409, confirmed that finding on August 25, 2025.
The Ombudsman program exists precisely for residents like these three. Nursing home residents, particularly those with dementia or serious illness, have limited ability to self-advocate. Many cannot make phone calls. Many do not know who to contact when their care changes or when a transfer happens abruptly. The Ombudsman notification requirement is supposed to ensure that someone outside the facility knows when a resident leaves, and can follow up.
When facilities skip that step, residents in the hospital may have no advocate checking on them. They return, or don't return, without anyone outside the building having been told they were gone.
The facility census at the time of the inspection was 86 residents. Inspectors reviewed three cases involving hospitalizations. All three had violations.
Avenue at Lyndhurst is located at 5442 Rae Road in Lyndhurst, a suburb east of Cleveland. The inspection was conducted as a complaint investigation, meaning someone raised a concern that prompted regulators to look.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the severity scale. That classification reflects the regulatory finding, not necessarily the experience of a resident with dementia and severe cognitive impairment who was hospitalized twice without anyone outside the facility being told.
Resident #98 needed maximum help to eat. She needed help brushing her teeth. She could not speak for herself in any setting, let alone a hospital. Whether anyone checked on her during either of those two hospitalizations, the inspection report does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVENUE AT LYNDHURST in LYNDHURST, OH was cited for violations during a health inspection on August 28, 2025.
Inspectors documented the failures during a complaint investigation completed August 28, 2025.
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.