Avenue at Lyndhurst: Residents Left in Soiled Briefs - OH
The scene unfolded on August 20 at Avenue at Lyndhurst when federal inspectors observed Licensed Practical Nurses #303 and #346 stationed at the nurses' desk from 3:10 p.m. to 3:37 p.m. When asked why they remained seated with multiple call lights activated, both staff members said they were conducting training.
Minutes earlier, inspectors had spoken with residents who described a pattern of neglect. Resident #15 told investigators at 3:24 p.m. that she needed to be put to bed and the nurse had promised to return shortly.
One minute later, Resident #9 explained she needed to be changed. The nurse had given her the same response. "Staff always come in, turn the light off and then leave and never return," Resident #9 told inspectors.
The facility's most serious violation involved a resident with dementia and diabetes who went unchanged for hours despite family intervention. Resident #69, admitted in September 2023, suffers from Type II diabetes, Alzheimer's disease, and morbid obesity. The resident requires complete assistance with eating, toileting, showering and dressing, and is incontinent of both bowel and bladder.
On June 27 at 5:02 a.m., the resident's power of attorney called the facility to report that Resident #69 had not been checked or changed "for a while." The resident had been put to bed at 9:30 p.m. the previous evening.
LPN #398 questioned the assigned nursing assistant, who admitted the last time she had checked on Resident #69 was at 1:00 a.m. The nurse then educated the assistant about the facility's policy requiring checks and changes every two hours.
Ten minutes later, the power of attorney called back, still concerned about the resident's care. LPN #398 found the nursing assistant providing care to a different resident. Only then did the assistant go to Resident #69's room, where she discovered the brief was "mildly saturated."
The resident had been left unchanged for more than four hours.
When interviewed on August 21, LPN #389 acknowledged that Resident #69's power of attorney "was very strict about times when the resident was changed." The nurse confirmed that Resident #69 was not being changed every two hours as required by facility policy, and said she had educated the nursing assistant about the requirements.
The Director of Nursing later told investigators she had directed LPN #389 to document the incident.
Avenue at Lyndhurst's own incontinence care policy, revised in March 2022, states the facility must ensure residents who are incontinent receive appropriate treatment and services to prevent urinary tract infections and restore continence when possible.
The violations stem from multiple complaints filed against the facility. Federal inspectors investigated the deficiencies under Master Complaint Number 2589262, which encompassed six separate complaint numbers dating back several months.
For Resident #69, the consequences extend beyond discomfort. The resident's combination of diabetes, dementia, and morbid obesity creates heightened risks when proper hygiene protocols fail. Prolonged contact with urine and feces can lead to skin breakdown, infections, and other serious complications in vulnerable elderly patients.
The inspection revealed a facility where promises of care repeatedly went unfulfilled. Residents pressed call buttons and received assurances that help was coming, only to wait indefinitely while staff attended to other priorities or remained seated at nursing stations.
The pattern affected multiple residents across the facility. While nurses claimed to be conducting training, residents remained in soiled conditions, waiting for the basic dignity of clean clothing and proper hygiene care.
Even when family members intervened directly, as Resident #69's power of attorney did with two phone calls in ten minutes, the response was delayed and inadequate. The nursing assistant only provided care after being questioned twice by supervisory staff, and only after the family's second call expressing continued concern.
The violations represent a fundamental breakdown in the most basic aspects of nursing home care. Residents who cannot toilet themselves depend entirely on staff to maintain their hygiene and dignity. When that care fails, as it did repeatedly at Avenue at Lyndhurst, residents suffer the physical and emotional consequences of prolonged neglect.
Resident #69 now rests in bed, changed and comfortable, according to the nursing notes. But the resident's power of attorney remains vigilant, calling to check on care that should happen automatically every two hours, day and night.
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.
When asked why they remained seated with multiple call lights activated, both staff members said they were conducting training.
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.