Health Center at the Renaissance: Fall Fracture Failure - OH
The resident, identified in inspection records only as Resident 2, had a documented history of impulsiveness, poor safety awareness, and non-compliance with transfer instructions. His care plan required one staff member to assist with every transfer, with hands-on contact maintained throughout. On February 10, 2025, none of that happened.
CNA #899 had been getting the resident's weight using a scale chair. She stood him up from his wheelchair, then walked away to retrieve the wheelchair and move it behind him. He fell before she got back.
Registered Nurse #952, who was assigned to the resident that day, described what happened plainly. CNA #899, she said, "trusted Resident #2 too much and should have kept hands on Resident #2." The resident complained of pain on the floor. EMS was called to lift him. He was transported to the hospital, where the fracture was confirmed.
The fall on February 10 was not the first. A fall investigation report from September 11, 2025, documented a separate unwitnessed fall in the bathroom, where the resident had attempted to transfer himself without locking his wheelchair brakes. No injuries that time. Staff responded by applying anti-roll backs to the wheelchair and educating him again on brake safety.
A care plan note added the following day, September 12, acknowledged the resident was non-compliant with transfer assistance and had a long history of forgetfulness. The interventions listed in response included redirecting him, using distraction, consulting psychiatric services, and helping him "understand why the behavior was inappropriate." The note said nothing about his fall risk or physical safety needs.
On September 24, inspectors observed Resident 2 sitting alone in his room in his wheelchair. His care plan called for him to be in a common area when out of bed. He was not. When inspectors attempted to speak with him about his falls, he could not recall having any.
The Director of Nursing, interviewed September 25, acknowledged the February fracture and confirmed the aide had failed to maintain adequate hands-on assistance. She also said she believed education was a sufficient intervention for this resident. Her reasoning: he was resistive to changes in care, and she wanted to preserve his independence. She said he had been educated repeatedly following falls and encouraged to use his call light, then acknowledged those interventions had not worked.
Physical Therapy Assistant #989 and Occupational Therapist #991, interviewed the same morning, confirmed that at the time of the February fall, Resident 2 required one-person assistance with contact guard assist for all transfers. They noted he had a history of poor follow-through on recommendations and was inconsistent about calling for help.
Federal inspectors cited the facility for actual harm, concluding that the failure to implement adequate, individualized interventions directly contributed to the resident's fracture. The complaint inspection, completed October 6, 2025, covered the period from the February fall forward and found no evidence that the facility had introduced any new or effective fall prevention strategies in the months between the fracture and the inspection.
What the record shows is a resident whose known risks, impulsiveness, forgetfulness, a pattern of self-transferring without assistance, were met repeatedly with the same response: tell him again. After he broke a bone, the answer remained the same.
He was sitting alone in his room when inspectors arrived, away from the common area his care plan said he should be in, unable to remember falling at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Health Center At the Renaissance from 2025-10-06 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
HEALTH CENTER AT THE RENAISSANCE in OLMSTED TWP, OH was cited for violations during a health inspection on October 6, 2025.
His care plan required one staff member to assist with every transfer, with hands-on contact maintained throughout.
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.