Twinsburg Post Acute: Sexual Assault of Blind Resident - OH
CNA #217 told the man to let the woman go. He kept holding her. Then he released her. The blind resident moved away from him immediately once his hands were off her.
The nursing assistant yelled. A licensed practical nurse came running from down the hall.
When LPN #283 entered the room, the male resident was sitting straight up in bed with a hospital gown on, his hand over his genitals. Resident #2, the blind woman, was confused. LPN #283 told investigators that Resident #2 would not have been forceful with anyone if she had walked into a resident's room on her own.
The male resident, identified in the inspection report as Resident #1, had been at the facility since at least February 2016. His diagnoses included vascular dementia. His care plan, dating to May 2023, documented a history of inappropriate sexual behavior related to cognitive impairment. The interventions written into that plan called for supervision during social gatherings and for staff to minimize his close interaction with female residents.
A second care plan, added in July 2024, noted he was inappropriately touching staff. It called for psychological counseling.
CNA #233 told inspectors she had been working with Resident #1 at the end of May 2025, cleaning his buttocks because he was incontinent. She turned him onto his side. While she was washing him, he began masturbating. She also reported he tried to touch her inappropriately during care. She said other CNAs had reported the same behavior. The facility, she said, had done nothing to address it.
Three other staff members, including an activity director, told inspectors that Resident #1 participated in activities and frequently sat in the dining room, and that he never required supervision. His care plan said otherwise, but nobody was following it.
The administrator, interviewed on July 8, initially told inspectors that Resident #2 was the perpetrator, not Resident #1. No explanation was provided for how that conclusion had been reached. It contradicted every account given by the staff who were present.
The facility also had a separate, compounding failure involving Resident #2. Her care plan required one-to-one supervision because she was not safe to ambulate independently. A physical therapy assistant confirmed this. The MDS nurse told inspectors that an intervention was considered active if it still appeared on the care plan after the revision date, and Resident #2's care plan still listed the one-to-one supervision requirement.
The administrator acknowledged on August 12 that the one-to-one supervision notation was a leftover from a previous incident, said it should have been removed, and stated it had been discontinued from the care plan that same day, during the inspection.
Inspectors identified three other residents on the same hall as Resident #1 who were independently mobile and had cognitive impairments.
The August 14 inspection was a complaint investigation. It was also, according to the report, an example of continued non-compliance from a survey conducted just seven weeks earlier, on June 25, 2025.
CNA #217 saw what happened. LPN #283 saw the aftermath. CNA #233 reported what she experienced weeks before. The care plans documented the risk going back two years. The blind woman moved away from him the moment he let go of her.
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.
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Last verified: October 19, 2026 · Our methodology
Twinsburg Post Acute in TWINSBURG, OH was cited for violations during a health inspection on August 14, 2025.
CNA #217 told the man to let the woman go.
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.