Avenue Care and Rehabilitation Center, The

In the surveyor’s words

From the most serious findings on record at Avenue Care and Rehabilitation Center, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 10, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed medical record review, review of the local police report, staff interviews, review of the National Weather Service forecast, review of the facility Elopement Policy and Procedure, review of Abuse, Neglect and Misappropriation Policy and Procedure, and review of camera footage, the facility failed to provide adequate supervision to prevent Resident #95, who had diagnoses of metabolic encephalopathy, malnutrition, and adult failure to thrive and severe cognitive impairment, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and actual harm leading to death beginning on [DATE] at approximately 8:40 P.M. […]

• Actual harm, isolatedF689Apr 25, 2024

  Based on closed record review and interview the facility failed to ensure Resident #94 was provided a safe transfer via mechanical lift to prevent a fall with injury. This affected one resident (#94) of five residents reviewed for accidents. The facility identified 20 additional residents (#11, #14, #17, #18, #24, #26, #27, #32, #33, #36, #41, #46, #47, #49, #55, #71, #75, #82, #84, and #92) who required a mechanical lift for transfers. The facility census was 87. Actual Harm occurred on 04/19/24 when Resident #94, who was a bilateral above the knee amputee, exhibited balance deficits, was moderately cognitively impaired and was dependent on staff for transfers sustained a fall during a staff assisted mechanical (Hoyer) lift transfer. […]

• Actual harm, isolatedF760Nov 21, 2023

  Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #84 was free from significant medication error. Actual Harm occurred on [DATE] at 12:00 P.M. when Resident #84 who received Hospice services was administered 5 milliliters (ml) of Morphine Concentrate 20 milligrams (mg) per ml by mouth which equaled 100 mg medication, ten times the amount ordered, resulting in a medication overdose. Resident #84 was monitored by the facility nurses for respiratory distress and failure and was administered Narcan for respiratory distress on [DATE] at 7:03 P.M. This affected one resident (Resident #84) out of five reviewed for medication administration. […]

• No harm, potential for more than minimal, widespreadF839Dec 18, 2025

  Based on interview and review of the Ohio e-licensure verification website, the facility failed to ensure nursing staff had an active nursing license. This had the potential to affect all residents residing in the facility. The facility census was 83.Findings include: Interview on 12/09/25 at 9:12 A.M. with the Administrator revealed the former Director of Nursing (DON) had resigned and Registered Nurse (RN) #256 assumed the role of Interim DON in October 2025.Review of the Ohio e-licensure verification website (https://elicense.ohio.gov/oh_verifylicense) on 12/10/25 at 7:11 A.M. revealed Interim Director of Nursing (DON)/RN #256's license was inactive, it had lapsed, with a listed expiration date of 10/31/25. Interview on 12/10/25 at 9:42 A.M. […]

• No harm, potential for more than minimal, widespreadF727Aug 13, 2025

  Based on review of staffing schedules and staff interview, the facility failed to maintain the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 87 residents currently residing in the facility. The census was 87.Findings include: Review of the nursing staff information and staff schedules for 06/28/25 and 07/04/26 revealed no RNs were present working in the facility during those days.On 08/13/25 at 3:15 P.M., interview with Human Resources Director (HRD) #890 verified the facility did not have an RN on duty on 06/28/25 and 07/04/26.This deficiency represents non-compliance investigated under Complaint Number OH00161573 (1254625), Complaint Number OH00164532 (1254632), and Complaint Number… […]