Twinsburg Post Acute: Sexual Abuse Unreported to Family - OH
She found out when a federal inspector called her.
The man, identified in inspection records as Resident #1, has lived at the Darrow Road facility since at least February 2016. By the time of the incident, he had been in the same second-floor room for more than three and a half years. According to his most recent assessment, he was severely cognitively impaired, diagnosed with vascular dementia. He could not advocate for himself. His daughter was on file as his representative specifically because of that.
On July 6, 2025, at 10:38 in the morning, an Administrator in Training at the facility created a self-reported incident documenting an allegation of sexual abuse involving Resident #1. The incident had been witnessed by a staff member. That same day, the facility transferred him out of his longtime room on the second floor and placed him in a room on the first floor.
Nobody called his daughter.
The facility's own records showed no documentation that she had been notified of either the sexual abuse allegation or her father's room change on July 6. When inspectors interviewed the Social Service Designee on July 8, she confirmed an incident of sexual touching had occurred and that the room change happened the same day. She confirmed there was no documentation of the representative being contacted. She confirmed Resident #1 had a representative and was not capable of speaking for himself.
The explanation the facility offered for the silence was that there was no phone number for the daughter in the electronic medical record.
That explanation did not hold up.
Inspectors found the daughter's phone number in the hospital record attached to Resident #1's file. They found it in a social services progress note dated September 11, 2023. They found evidence that a unit manager had called her as recently as April 17, 2025, less than three months before the abuse incident, to notify her of new orders for her father. The Social Service Designee told inspectors she had personally spoken to the representative by phone approximately two months before the incident. She said the number had been on the face sheet in the electronic record and she did not know who removed it.
When the administrator was interviewed on July 8, he confirmed the representative was never notified of the July 6 incident. His reason: there was no telephone number for her on file.
The daughter told inspectors the facility had not contacted her about any incident involving her father on July 6. She did not know he had been moved to the first floor. She said she wanted to be notified of any changes involving her father and told the inspector she was heading to the facility immediately to find out what had happened.
The second violation in the inspection report is quieter but follows the same pattern — a task ordered, a task ignored, and no one able to explain why.
Resident #20 was seen by a Certified Nurse Practitioner on August 7, 2025. The CNP ordered a urinalysis. A licensed practical nurse confirmed the order had been placed. The urine was collected from the resident that same day. Then it sat. It was never sent to the laboratory.
When the Director of Nursing was interviewed on August 11, she confirmed there were no urinalysis results in Resident #20's medical record. She confirmed the urine had been obtained on August 7 and never sent out. She said she did not know why. She confirmed it should have been sent per the CNP's orders.
The CNP, reached by phone that same afternoon, confirmed she had ordered the urinalysis on August 7 and said she was never told it hadn't been completed.
A pharmacy recommendation had also gone unaddressed for Resident #20. The Director of Nursing confirmed that recommendation had not been completed either, and added that any nurse could have handled it.
There is no indication in the inspection record that the CNP was ever looped back in to reorder the test, or that Resident #20's urine was ever sent to a laboratory before the inspection closed.
The inspection was conducted as a complaint investigation, initiated under two separate complaint numbers. Inspectors from the Centers for Medicare and Medicaid Services completed their review on August 14, 2025.
What the records show, taken together, is a facility where the mechanisms for following through on basic obligations — sending a lab specimen, calling a family member — broke down without anyone noticing or correcting course. The CNP who ordered the urinalysis assumed it had been done. The daughter who was supposed to be called assumed she would be. The phone number that should have been on the face sheet was gone, and no one knew who took it off.
Resident #1 has lived at Twinsburg Post Acute for nearly a decade. He has severe dementia. He was sexually abused, moved to a strange room on a different floor, and spent at least two days in that new room while his daughter, forty minutes away or forty seconds away, had no idea any of it had occurred.
She said she was coming straight to the facility.
The inspection record does not say what she found when she got there.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 19, 2026 · Our methodology
Twinsburg Post Acute in TWINSBURG, OH was cited for abuse-related violations during a health inspection on August 14, 2025.
She found out when a federal inspector called her.
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.