Avenue at Lyndhurst

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 18, 2026

  Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and/or promote pressure ulcer healing for Resident #29, #83 and #100. This affected three residents (Resident #29, #83 and #100) of six residents reviewed for pressure ulcers. The facility census was 88.Actual harm occurred on 03/26/26 (13 days after admission) when Resident #100 who was severely cognitively impaired and high risk for pressure ulcer development with a history of pressure ulcers and skin disorders developed pressure ulcer, first identified to be Stage III (a severe wound featuring full-thickness skin loss where subcutaneous fat is visible) to the right groin. […]

• Actual harm, isolatedF689Jun 18, 2026

  Based on medical record review, staff and resident interviews, review of the facility investigation, review of staff witness statements, review of hospital documents, review of the manufacturers recommendations, and policy review, the facility failed to ensure Resident #99's was safely transferred in a Hoyer lift, failed to implement effective fall preventive measures to prevent multiple falls for Resident #82, failed to ensure fall interventions were implemented for Resident #10, and failed to ensure thorough fall investigations were completed to determine root cause of falls and proper fall interventions to implement. This affected four residents (Resident #65, #76, #82, and #99) of eight residents reviewed for falls. […]

• Actual harm, isolatedF692Jun 18, 2026

  Based on record review, interview and facility policy review, the facility failed to provide necessary nutritional and hydration care and services for Residents #25, #46, #76, #77, #83, #99, and #100). This affected seven residents (Resident #25, #46, #76, #77, #83, #99, #100) out of 12 residents reviewed for nutrition. The facility census was 88. Actual harm occurred on 05/07/26 after Resident #83, who had cognitive impairment with a history of malnutrition, nutrition and hydration status was not properly monitored and poor oral intakes were not treated, resulting in the resident experiencing weight loss, significant dehydration and acute kidney injury. Resident #83 required hospitalization, intravenous (IV) fluids, and treatment for a urinary tract infection.Findings include: 1. […]

• Actual harm, isolatedF697Feb 11, 2025

  Based on observation, medical record review, hospital record review, facility policy review and staff and resident interview, the facility failed to develop and implement a comprehensive, individualized and effective pain management program for Resident #77 who was admitted with acute pain and difficulty with moving due to pain to the left foot and a vascular wound. Actual Harm occurred beginning on 01/18/25 when Resident #77 did not receive ordered pain medication, Tramadol (an opioid pain reliever). The resident was admitted to the facility (on 01/18/25) with a physician order for Tramadol 25 milligram (mg) every 12 hours as needed for pain for up to seven days; however, the medication was not administered until 01/21/25 (three days after admission). […]

• No harm, potential for more than minimal, widespreadF606Jun 18, 2026

  Based on record review, interview and review of the facility policy, the facility failed to employ staff free of disqualifying offenses. This had the potential to affect all 88 residents residing in the facility. Findings include: 1. Review of Human Resource Manager (HRM) #439's personnel file revealed a date of hire of 10/08/25. The file included a employee corrective action form dated 04/02/26 for termination as HRM #438 had been charged/convicted of an exclusionary offense. Review of undated Cuyahoga County Clerk of Courts docket information included in HRM #439's personnel file revealed she was indicted on 12/10/25 with pre-trials held on 01/06/26, 02/25/26 and 03/05/26. Charges listed included 2913.05 (telecommunications fraud) and 2913.02 (grand theft). […]