The Avenue at Warrensville Care and Rehabilitation Center

The Warrensville Heights police are investigating the death of an elderly woman after she was found unresponsive outside of The Avenue at Warrensville Care and Rehabilitation Center on Christmas Eve. According to the Warrensville Heights police report, an 84-year-old woman was last seen by a nurse at 8:40 p.m. on December 23, 2024. She was later found unresponsive outside of The Avenue at Warrensville Care and Rehabilitation Center Nursing Home on December 24, 2024. Temperatures got down near freezing on December 24, 2024.

The Avenue at Warrensville Care and Rehabilitation Center Nursing Home is located at 4120 Interchange Corporate Center Road in Warrensville Heights, Ohio 44128. It has 97 beds. It currently has a three star rating. It has a two star rating for staffing.

On average, there are 91.2 residents per day. So it is close to capacity. Registered nurses spend an average of 27 minutes per resident per day. The national average is 40 minutes. The average in Ohio is 37 minutes. So this number is significantly less than the national average.

The number of LPN hours per resident per day is 1 hour and 6 minutes. The national average is 53 minutes, and the Ohio average is 58 minutes.

This can be a source for concern. When the LPN hours are higher than average, and the registered nurse hours are far lower than average, it may mean that the nursing home is trying to save money by hiring more LPNs to whom they pay less, and fewer RNs to whom they pay more. Registered nurses are more educated than licensed practical nurses. They are able to do more things because they have more education. And so a nursing home with far lower than average registered nurse hours per resident per day and higher than average LPN hours per resident per day is a nursing home where the owners have made a decision to staff the facility with less educated individuals.

The amount nurse aide hours per resident per day is 2 hours and 15 minutes, which is right about the national average, and a little higher than the Ohio average.

The facility has total nurse staffing turnover of 56.6%, which means that nearly half the staff turns over every year. When a facility has staff turnover, this can be of significant concern. Obviously, a nurse or an aide who has worked at a facility for a long time can get to know the residents. They can get to know their needs and their preferences. When you have a lot of staff turnover, and you have a lot of new people coming in on a regular basis, or when you have a nursing home that uses a lot of agency nurses, you have people constantly coming in who are unfamiliar with the residents of the nursing home. They need to learn the needs of the resident. This has a significant negative impact on resident care. Obviously, staff who are unfamiliar with the residents have a more difficult time providing them with appropriate care.

Nursing homes are supposed to conduct a comprehensive assessment of every resident. This comprehensive assessment is supposed to lead to a comprehensive care plan that addresses all of the residents' needs. That care plan is supposed to be constantly updated and changed as the residents' needs change.

If a resident comes in, and they're at risk for falls, and the nursing home prepares a care plan to address that need for falls, and then the resident has a fall, the nursing home is supposed to reconsider that care plan and come up with additional interventions to keep that resident safe.

Pursuant to the Ohio Nursing Home Residents Bill of Rights, every nursing home in Ohio is obligated to provide every single resident with a safe environment.

Pursuant to the Code of Federal Regulations, the federal law that applies to the care of nursing home residents in a nursing home, every nursing home in the country is obligated to provide their residents with adequate supervision to prevent accidents. If a nursing home is understaffed, it's very hard to keep the residents safe, and it's very hard to provide them with adequate supervision.

Tragically, the woman at The Avenue at Warrensville Care and Rehabilitation Center in Warrensville eloped out of the facility. Most of us think of elopement as when two people leave town to go get married. Unfortunately, in the nursing home business, elopement means leaving the facility unattended. This resident left the facility unattended in the wintertime when the weather was cold and tragically was found dead. Furthermore, the nursing home wasn't aware that she was gone for an entire day. According to the police report, the last time that she was seen in the facility was on December 23 at 8:40 p.m. She was found unresponsive on December 24, 2024.

Nursing homes are obligated to provide their residents with appropriate care. They are obligated to provide them with a safe environment. They are obligated to provide them with adequate supervision. And they are obligated to provide all these things 24 hours a day, 7 days a week, 365 days a year. Nursing homes are obligated to provide their residents with appropriate care and adequate supervision on Christmas Eve, on Christmas Day, on New Year's Eve, on New Year's Day, on Thanksgiving, on the weekends, and every single day of the year.

Nursing homes, like any business, experience staff who become ill, particularly over the winter. They experience staff who ask to be excused from work, particularly over the holidays. However, nursing homes are legally obligated to maintain an appropriate number of properly trained staff to meet the needs of their residents at all times. They're obligated to have an appropriate number of staff members on Christmas Eve, on Christmas Day, on New Year's Eve, on New Year's Day.

Apparently, the woman who eloped from The Avenue was last seen at 8:40 p.m. on December 23, 2024. She was not in her room at 9:30 p.m. on December 23, 2024. The staff at The Avenue at Warrensville Nursing Home did not call the Warrensville police until 9 hours later. The Warrensville police responded immediately, and shortly after they arrived at the nursing home, they found the woman outside on a patio of the facility. The woman was unresponsive, and she was taken to a local hospital where she later died. The woman has only been at the facility since December 18, 2024.

This is also of concern. It is clear that the staff at the nursing home did not look very hard for this woman. She was right on the patio. If they had looked for her shortly after she went outside they likely would have found her and she likely would not have died. If they had called the police right away they would likely have found her and she would likely not have died. This tragedy could have been prevented with proper care.

The Avenue at Warrensville Care and Rehabilitation Center was issued a federal fine on April 25, 2024 of $25,847.00. It was fined on February 28, 2022 in the amount of $2,320.00. It was fined on February 21, 2022 in the amount of $1,988.00. It was fined on January 3, 2022 in the amount of $1,638.00. The Avenue at Warrenville Care and Rehabilitation Center is part of the Embassy Healthcare Group of nursing homes.

There are a number of parts of this story that are extremely tragic. First and foremost, all elopements in nursing homes are preventable. Nursing residents, who are not safe to move about the nursing home on their own, should be placed in a locked unit where they cannot leave the facility unattended. Residents who are at risk of elopement can wear wander guards, which are devices that go on their clothing or their wrist that sound an alarm if they get near a door. The outside doors should be locked so the residents who are mentally compromised can't walk out of the facility unattended. As indicated above, nursing homes are obligated to provide their residents with adequate supervision to prevent accidents. Adequate supervision means having eyes on the nursing home residents with sufficient frequency that their not able to leave the facility unattended.

At The Dickson Firm, we've also seen cases where residents have gotten into the kitchen and consumed dangerous products. Nursing home are obligated to provide their residents with a safe environment and give them adequate supervision so things like this do not happen.

It's also extremely egregious that the nursing home did not contact the police immediately. At 9:30 p.m. on December 23, 2024 when the staff was unable to locate this woman, they should have immediately called the police. Furthermore, the fact that she was found on the patio indicates that the staff did very little to locate her. Obviously, if they were unable to find her in the facility, they should have immediately searched the grounds. She was found right outside the facility on the patio. Clearly, she had some kind of confusion such that she did not realize that sitting out on the patio when it was so cold was dangerous for her.

At The Dickson Firm, we've handled numerous cases involving elopement. We've represented families who have lost loved ones as a result of neglect and abuse by various nursing homes, which have allowed their residents to leave the various facilities unattended. We have represented families where the resident has fallen and suffered a fracture. We have represented families where the resident has suffered harm because of the cold weather.

There are numerous hazards outside of nursing homes for a resident who is not able to walk around on their own. One of the main reasons people admit their loved ones to a nursing home is to keep them safe. They admit their loved ones because their loved ones cannot be at home left on their own and still be safe. Nursing homes have a duty to keep these people safe. This is a very egregious story of significant neglect resulting in a tragic outcome for this family.

If someone you love has been neglected or abused in a nursing home, please call us at The Dickson Firm at 1-800-OHIO LAW, as it would be our pleasure to help you in any way that we can.