Avenue at Broadview Heights

In the surveyor’s words

From the most serious findings on record at Avenue at Broadview Heights, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 15, 2026

  Based on observation, closed record review, review of Emergency Medical Services report, review of hospital records, policy review and interview the facility failed to follow Resident #62's physician orders and implement care planned interventions to ensure Resident #62 was monitored appropriately and timely treated for an acute change of condition, and failed to ensure adequate skin monitoring was completed to timely identify and treat areas of Resident #62's skin breakdown. The facility also failed to ensure Resident #39's new medical diagnoses of type two diabetes was timely treated.Actual Harm occurred beginning on 02/18/25 at 7:47 P.M. […]

• Actual harm, isolatedF690Oct 21, 2025

  Based on observation, interview, record review, review of the facility policy, and review of hospital records, the facility failed to properly assess and monitor Resident #43 and Resident #59's urinary condition to timely identify and treat signs and symptoms of a urinary tract infection. Actual Harm occurred on 06/13/25 at 9:07 A.M to Resident #59 when the resident's care planned interventions to monitor urine output and orders to irrigate the catheter were not implemented, symptoms of a UTI were not timely identified, and the resident presented with an emesis, tachycardia with a heart rate of 143, complaints of being cold, had a large diarrhea bowel movement and chills. On 06/13/25 at 1:12 P.M. […]

• Actual harm, isolatedF686Sep 11, 2024

  Based on record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers, and to ensure wound care was completed as ordered to ensure Resident #72 skin was maintained and the resident did not develop an in-house stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the left buttock. […]

• No harm, potential for more than minimal, patternF694Sep 7, 2023

  Based on observation, interview and record review the facility failed to ensure physician orders and care plans were in place for the care of intravenous (IV) lines to prevent infection/complications. This affected five of five residents identified by the facility as having IV access, Residents #1, #3, #16, #18 and #57. Findings include: Review of Resident #57's medical records revealed an admitted [DATE]. Diagnoses included multiple sclerosis (MS), muscle weakness and cognitive deficits. Review of Resident #57's MDS assessment dated [DATE] revealed Resident #57 had impaired cognition, and required total dependence for bed mobility, transfers, toileting and personal hygiene. Observation of Resident #57 on 09/05/23 at 9:15 A.M. […]

• No harm, potential for more than minimal, patternF584Mar 30, 2023

  Based on observation and interview the facility failed to ensure towels and washcloths were available on the nursing units for provision of resident care. This affected Residents #32, #53 and #66 and had the potential to affect all 69 residents residing in the facility. Findings include: Observation on 03/27/23 at 8:53 A.M. revealed Licensed Practical Nurse (LPN) #237 attempting to locate towels and washcloths to provide care for Resident #32. LPN #237 stated the facility often did not have washcloths or towels available for resident care. Observation of the clean linen closet with LPN #237 revealed one towel and no washcloths. Interview on 03/27/23 at 9:18 A.M. with LPN #237 revealed Resident #53's family was upset because they observed LPN #237 using a pillowcase to clean Resident #53. […]