Twinsburg Post Acute: Hip Fracture Unreported - OH
The incident at Twinsburg Post Acute occurred on May 20, when Resident #2 fell in another patient's room during what one witness described as twilight hours. Staff helped her back to bed, but never reported the fall or injury to her doctor, despite federal requirements to notify physicians of accidents and injuries.
Resident #2's daughter arrived at 2:55 p.m. that day to find her mother unable to move without screaming in pain. The daughter told inspectors she immediately went to nurses, reporting her mother couldn't get up or walk and that any movement caused her to scream.
"There was no way my mom could have walked on it, just moving it made her scream in pain," the daughter said.
Staff told the daughter that her mother had wandered into someone's room, fell down, broke her hip, walked on it, and then they assisted her back to bed. The daughter said it took another 45 minutes to an hour before the facility finally transferred her mother to the hospital.
The morning of the fall, CNA #211 had fed Resident #2 in bed and provided incontinence care. The aide noted the resident was lying in a fetal position, which was unusual since she typically wandered throughout the day. CNA #211 said she didn't have to straighten the resident's legs to provide care that morning.
"Resident #2 didn't scream until her daughter straightened her legs out," CNA #211 told inspectors.
LPN #277, the resident's primary charge nurse that day, was on her lunch break when she received a call from the unit manager saying the resident's daughter was there and the resident was in pain. The nurse said she had given Resident #2 her medications that morning while the woman was in bed and that she didn't appear to be in pain then, though she didn't have to move her.
The unit manager wanted LPN #277 to write a statement saying the resident had fallen during her day shift. The nurse refused.
Resident #36, whose room the injured woman had wandered into, recalled the incident during an interview with inspectors. She said a female resident came into her room around twilight time, before morning, a couple months earlier.
"It looked like the resident was dancing, fell, the man picked her up, she walked out, then she didn't know what happened," Resident #36 said. She confirmed she turned on her call light and yelled for help when she saw the resident in her room.
The facility's own policy, revised in February 2021, requires staff to promptly notify residents, their attending physicians, and representatives of changes in medical condition or status. The policy specifically states nurses must notify the resident's attending physician when there has been an accident or incident involving the resident or discovery of injuries of unknown source.
Despite this clear requirement, no physician was notified of Resident #2's fall or suspected hip fracture. No documentation exists of the dressing that was reportedly placed on her left arm, dated the same day as the fall.
CNA #211 confirmed that Resident #2, who usually got up during night shift and walked around during the day, never got up at all on May 20. The aide was on lunch break when the resident was finally transferred to the hospital, hours after the initial fall.
The failure to document and report the injury represents continued non-compliance for Twinsburg Post Acute, following a previous survey on June 25. Federal inspectors classified the violation as causing actual harm to residents.
The inspection was conducted in response to a complaint filed with state regulators. The facility's failure to follow basic reporting requirements meant a resident with a broken hip spent hours in excruciating pain, unable to receive proper medical attention until her daughter's intervention forced staff to act.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Twinsburg Post Acute from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Twinsburg Post Acute in TWINSBURG, OH was cited for violations during a health inspection on August 14, 2025.
The incident at Twinsburg Post Acute occurred on May 20, when Resident #2 fell in another patient's room during what one witness described as twilight hours.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.