Avenue Care And Rehabilitation Center, The
AVENUE CARE AND REHABILITATION CENTER, THE in WARRENSVILLE HEIGHTS, OH — inspection on October 29, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the hospital, as he was having an overall decline which they felt was he was in the process of transitioning.An interview on 10/28/25 at 7:00 A.M. with Resident #67's Power of Attorney (POA) confirmed the nurse did notify them via FaceTime video call on 10/26/25 at 12:23 A.M. to show her Resident #67 had the call light cord around his neck.
The POA stated the nurse was concerned Resident #67 might be trying to hurt himself.
The POA stated Resident #67 was not strong enough to strangulate himself and the POA watched as Resident #67 allowed the nurse to remove the cord.
Interviews on 10/28/25 from 4:45 P.M. to 4:50 P.M. with Unit Manager RN #333 and LPN #350 revealed any resident with suspected suicidal ideation or self-harm would not be left alone and a phone call to the physician would be placed immediately. LPN #350 stated all dangerous items would be removed. An interview on 10/28/25 at 8:45 A.M. with RN #301 revealed she worked the night shift and Resident #67 wrapped the call light cord around his neck. RN #301 stated at 12:30 A.M. CNA #387 alerted her Resident #67 had a call light cord around his neck. RN #301 FaceTime video called Resident #67's POA.
All cords were removed from the room, and the CNAs took turns providing one-on-one observation the whole night until Hospice nurses came in the next morning because RN #301 was concerned Resident #67 may try to hurt himself. RN #301 stated she texted the physician after the incident happened, did not received a response, and did not call the physician until 9:04 A.M. RN #301 confirmed this was over eight hours after Resident #67 had been found with the call light cord around his neck. RN #301 stated the note on 10/26/25 at 3:18 A.M was a late note summarizing the events that occurred around 12:30 A.M. An interview on 10/29/25 at 9:35 A.M. with CNA #387 revealed CNA #379 first found Resident #67 with a cord around his neck. CNA #379 never left him. CNA #387 could not remember the time she alerted the nurse . CNA #387 observed Resident #67 to be confused and in distress when she observed Resident #67 in his bed with the cord around his neck. CNA #387 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 9:46 A.M. with CNA #379 revealed she observed Resident #67's call light on, and it was unusual for Resident #67 to ring his call light. CNA #379 stated she observed Resident #67 with the call light cord around his neck and that was a change in behavior for Resident #67. CNA #379 verified the POA was video called to observe the situation and speak to Resident #67.Interview on 10/29/25 at 11:00 A.M. with Unit Supervisor RN #333 revealed if a resident had a change in condition the nurse needed to report the findings to the physician immediately for interventions, and this needed to be done by a phone call regarding a change in condition, not a text message.
Review of the facility policy titled Resident Change In Condition, dated 07/28/22, revealed an Acute Change in Condition was a sudden, clinically important deviation from a resident's baseline.
Without interventions the condition may result in complications or death . In the event the physician could not be reached within thirty (30) minutes and the resident maintained stable condition, 911 would be called for transport, then the doctor would be updated on transfer.This deficiency resulted from incidental findings during investigation of Complaint Number 2653275 and represents continued non-compliance from the survey dated 08/13/25.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue Care and Rehabilitation Center, The
4120 Interchange Corporate Center Road Warrensville Heights, OH 44128
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility policy titled, Activities of Daily Living (ADL's) dated March 2023 revealed to specify the responsibility to create and sustain an environment that humanizes and individualizes each residents quality of life by ensuring all staff , across all shifts and departments, understand the principals of quality of life, and honor and support these principals for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.
The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.
The facility will provide care and services for the following activities of daily living: Hygiene, mobility, elimination (toileting), repositioning, dining and communication. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
This deficiency represents noncompliance investigated under complaint number 2648929 and represents continued non-compliance from the survey dated 08/13/25.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue Care and Rehabilitation Center, The
4120 Interchange Corporate Center Road Warrensville Heights, OH 44128
SUMMARY STATEMENT OF DEFICIENCIES
direct care staff: An interview on 10/27/25 at 9:58 A.M. with LPN #393 revealed the CNAs were burnt out from working with less than sufficient staffing to care for residents. LPN #393 revealed that some days the facility was working short of staff and on those days the residents who required assistance to get out of bed were left in bed.An interview on 10/27/25 at 10:01 A.M. with CNA #359 revealed CNA #359 stated we try our best, at times showers are not completed so we will just wash them up in bed instead.
Residents can't always get up or lay down timely, then they want water or Boost, but we can't always get to that. CNA #359 revealed sometimes they report to work in the mornings, and the residents were soaked and wet because the third shift stated they did not have enough staff.
First shift also did not have enough staff either.An interview on 10/27/25 at 10:55 A.M. with CNA #362 revealed there was not enough staff to complete daily tasks. CNA #362 revealed residents on their assignments who were incontinent were usually changed one time per shift (a shift of 12 hours) and residents often received bed baths instead of showers because there were not enough staff to provide showers.An interview on 10/27/25 at 11:00 A.M. with CNA #354 revealed there were not enough CNAs, so residents were not changed timely. CNA #354 stated residents were changed two times during a 12 hour shift due to not having enough time to meet all the resident care needs.
This deficiency represents noncompliance investigated under complaint number 2648929.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Avenue Care and Rehabilitation Center, The
4120 Interchange Corporate Center Road Warrensville Heights, OH 44128
SUMMARY STATEMENT OF DEFICIENCIES
Federal health inspectors cited AVENUE CARE AND REHABILITATION CENTER, THE in WARRENSVILLE HEIGHTS, OH for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-10-29.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of AVENUE CARE AND REHABILITATION CENTER, THE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-18.