The October 6 state inspection revealed CNA #718 mimicked Resident #48's moaning noise during a Hoyer lift transfer, then walked toward the bathroom while continuing to imitate the sounds. The administrator placed the aide on the facility's do-not-rehire list after watching the video but failed to report the incident to state authorities as required by the nursing home's own policy.
Video clips showed the incident unfolding during routine care. Resident #48 made moaning sounds indicating pain while being transferred into bed via mechanical lift by CNA #718 and LPN #894. The nursing assistant asked if she was doing something wrong, then began mimicking the resident's pain sounds.
The situation escalated during incontinence care. Additional footage revealed Resident #48 yelling out in pain while CNA #718 provided care in bed. The aide told the resident, "You have to help me and stop resisting."
CNA #718 then placed both hands on Resident #48's right hip and pushed him onto his left side as he yelled out in pain. LPN #894 entered the room and asked the resident to verify his name while the aide continued attempting to turn him.
The licensed practical nurse placed both hands on Resident #48's right side to hold him in place on his left side while CNA #718 continued providing care. When LPN #894 asked if the resident was in pain, she stated, "I just gave you Tylenol."
The aide told Resident #48 to turn toward her. When the resident did not move, CNA #718 placed both hands on his left side and pulled him all the way over onto his right side, holding him in place. The resident continued yelling out in pain while the aide asked, "What's the matter?"
After completing care, CNA #718 pushed the resident's bed against the wall using her upper legs.
The administrator revealed that prior to reviewing the video footage, CNA #718 was sent home. After watching the clips, the aide was placed on the do-not-rehire list.
State inspectors found no record of the incident in Ohio's SRI tracking system for certification and licensing. The administrator confirmed during a September 25 interview at 8:01 A.M. that the alleged abuse was never reported to the State Survey Agency.
The facility's own policy, revised November 28, 2016, states that all residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy specifically prohibits corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms.
The policy document clearly states that alleged violations would be reported to the State Survey Agency. Inspectors determined the facility failed to implement this requirement regarding the allegation against CNA #718.
The inspection was conducted in response to Complaint Number 1374287. Federal regulators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The incident highlights ongoing concerns about staff conduct and administrative oversight in nursing facilities. Video surveillance captured not only the aide's unprofessional behavior but also the resident's obvious distress during what should have been routine care.
The failure to report extended beyond the initial incident. Despite having clear video evidence of staff mocking a resident's pain and using excessive force during care, administrators kept the matter internal rather than notifying state authorities as their own policies required.
LPN #894's involvement raises additional questions about supervisory oversight. The licensed nurse was present during the incident, assisted in restraining the resident, and offered medication as a response to the patient's obvious distress.
The timing of pain medication administration also appears problematic. The LPN stated she had "just gave you Tylenol" when the resident expressed pain, suggesting the medication was given during or immediately before the incident rather than as a preventive measure.
The use of physical force to reposition Resident #48 contradicts basic care standards. The aide's actions of pushing, pulling, and forcibly holding the resident in position while he screamed demonstrates a fundamental failure to respond appropriately to patient distress.
The administrator's decision to place CNA #718 on the do-not-rehire list suggests recognition that the behavior was unacceptable. However, the failure to report the incident to state authorities potentially prevented broader investigation and oversight.
Ohio's tracking system showed no prior incidents regarding Resident #48, indicating this was either an isolated event or part of a pattern that had gone unreported. The lack of documentation raises questions about the facility's incident reporting practices beyond this single case.
The inspection occurred as part of a complaint investigation, suggesting external concerns prompted the review. The specific nature of the original complaint was not detailed in the inspection report.
Federal regulations require nursing homes to immediately report suspected abuse to state authorities and the facility administrator. The Health Center at the Renaissance had established policies acknowledging these requirements but failed to follow them when confronted with video evidence of staff misconduct.
The violation represents a breakdown in both direct care and administrative oversight. While CNA #718 engaged in unprofessional conduct, the facility's failure to report the incident compounded the problem by potentially shielding the behavior from proper investigation.
Resident #48 experienced not only physical discomfort during necessary care but also the indignity of having pain sounds mocked by the person providing assistance. The psychological impact of such treatment extends beyond the immediate physical effects.
The case demonstrates how video surveillance can reveal staff behavior that might otherwise remain hidden, but also shows that having evidence means nothing without proper administrative response and regulatory reporting.
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
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