Twinsburg Post Acute
Twinsburg Post Acute in TWINSBURG, OH — inspection on August 14, 2025.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired.
Review of the medical record for Resident #1 face sheet revealed Resident #1 had a representative who was his daughter.
The face sheet in the electronic medical record did not have a telephone number available for Resident #1's representative.
The medical record revealed Resident #1's representative's telephone number was provided in the hospital record. On 09/11/23, a social services progress note documented the resident representative's telephone number.
The progress note dated 04/17/25 completed by Unit Manager #293 revealed Resident #1 received new orders and a telephone call was placed to Resident #1's daughter making her aware of the new orders.
Review of the facilities Self-Reported Incident (SRI) revealed on 07/06/25 at 10:38 A.M., a SRI was created by Administrator in Training (AIT) #351.
The SRI had allegation of sexual abuse involving Resident #1 and it was witnessed by a staff member.
Review of the resident census in Resident #1's electronic medical record revealed Resident #1 resided on the second floor in the same room from 12/14/21 through 07/06/25. On 07/026/25, Resident #1 was transferred to a room on the first floor of the facility. Resident #1's medical record did not have any documentation that Resident #1's responsible party was notified of a sexual abuse incident involving Resident #1 and Resident #1's room change on 07/06/25.
Interview on 07/08/25 at 11:59 A.M. with Social Service Designee (SSD) #334 revealed she spoke Resident #1's representative on the telephone about two months ago. SSD #334 stated the telephone number was there on Resident #1's face sheet in the medical record and she was unaware of who took the telephone number off the face sheet. SSD #334 confirmed an incident occurred regarding sexual touching and Resident #1's room was changed on 07/06/25. SSD #334 confirmed Resident #1 did not have any documentation of Resident #1's representative being notified of any occurrence on 07/06/25 and SSD #334 confirmed Resident #1 had a representative in place and Resident #1 was not his own person.
Telephone interview on 07/08/25 at 12:16 P.M. with Resident #1's representative revealed the facility staff did not contact her for any incident involving Resident #1 on 07/06/25. Resident #1's representative was unaware Resident #1 moved to the first floor on 07/06/25. Resident #1's representative stated she wanted to be notified of any changes involving Resident #1 and stated she was coming straight to the facility to obtain additional information about the incident involving Resident #1 on 07/06/25.
Interview on 07/08/25 at 3:11 P.M. with Administrator confirmed Resident #1's representative was never notified of the incident on 07/06/25 due to there was no telephone number for her.
Review of the facility policy titled Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status.
This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number OH00167210 (138517).
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the sign in visitor log dated 05/20/25 revealed Resident #2's
was sent to the hospital after that. A telephone interview on 08/06/25 at 6:33 P.M. with LPN #277
revealed she was on her lunch break (did not recall the time) when she received a call from UM #293 indicating Resident 2's daughter was there and Resident #2 was in pain. LPN #277 stated she gave Resident #2 her medications that morning when the resident was in bed. LPN #277 didn't know how CNA #211 changed her, but Resident #2 did not get out of the bed. UM #293 wanted LPN #277 to write a statement saying she fell on her day shift and the LPN refused to write one. LPN #277 revealed Resident #2 did not appear to be in pain that morning, but she did not have to move her.
Interview on 08/07/25 at 8:22 A.M. with Resident #36 revealed she recalled a resident coming into her room. Resident #36 stated a female resident fell, didn't know who the female resident was, it had occurred a couple months ago around twilight time, before morning. Resident #36 stated 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 confirmed when she saw the resident in her room, she turned her call light on and yelled for help.
The man that came in was staff.
Interview on 08/07/25 at 8:45 A.M. with CNA #211 revealed she was Resident #2's primary CNA on 05/20/25. CNA #211 stated on the morning of 05/20/25, CNA #211 fed Resident #2 in bed. Resident #2 was usually up wandering but did lay down for naps throughout the day.
However, Resident #2 did not get up at all on that day. CNA #211 stated she was on lunch break when Resident #2 was transferred to the hospital. CNA #211 stated she changed Resident #2 that morning, and she did not seem like she was in pain, she was lying in a fetal position, which was not her usual as she would wander typically, and was on her side. CNA #211 stated she didn't have to straighten Resident #2's legs out to provide incontinence care. CNA #211 confirmed she provided incontinence care that morning only and confirmed she was Resident #2's primary CNA on that day. CNA #211 revealed Resident #2 didn't scream until her daughter straightened her legs out. Resident #2 did not get up at all that day. CNA #211 stated Resident #2 did usually get up on night shift and walked around during the day but didn't on 05/20/25.
Review of the facility policy titled, Change in a Resident's Condition or Status revised February 2021 revealed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status.
The nurse would notify the resident's attending physician or physician on call when there had been a (an) accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/emotional/mental condition.
This deficiency represents non-compliance investigated under Complaint Number 2581344.
This is an example of continued non-compliance from the survey dated 06/25/25.
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57 had impairment on one side of the upper extremity and both sides of the lower. Resident #57 was dependent on staff for all activities of daily living (ADL). Resident #57 was at risk for pressure ulcers, had one stage IV pressure ulcer and one unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar).
Review of the physician orders for Resident #57 revealed on 05/23/25, an order for the right dorsum foot to cleanse right dorsum foot with Dakin's 0.25% solution, blot dry, apply calcium alginate with silver, ABD and kerlix.
Change daily and as needed every day shift for wound management.
Observation 07/08/25 at 4:30 P.M. revealed Wound Care Nurse (WCN) #292 and Unit Manager (UM) #293 were going to provide wound care for Resident #57. WCN #292 and UM #293 confirmed the date on the dressing to Resident #57's wound on the right foot was dated 07/06/25 the initials were [Licensed Practical Nurse (LPN) #283].
Observation after removal of the dressing revealed the old dressing had a heavy drainage and foul odor.
The tissue surrounding the edges of the wound bed was white/emaciated.
The appearance and odor was verified by WCN #292.
Record review of the nursing staff assignment sheets and timecards and interview on 07/09/25 at 9:00 A.M. with the Administrator and UM #293 confirmed LPN #283 worked at the facility on 07/06/25. LPN #283 did not work on 07/07/25 or 07/08/25.
The Administrator and UM #293 confirmed LPN #283 completed the dressing change on 07/06/25 and the dressing change was not completed again until 07/08/25.
Review of the facility's undated policy titled Wound Care revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing.
Dress the wound and mark tape with initials, time, and date and apply to dressing.
This deficiency represents non-compliance investigated under Complaint Number OH00167210 (1381513).
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of a care plan dated 05/15/23 revealed Resident #1 had a history of inappropriate sexual behavior at times related to cognitive impairment.
Interventions included to provide supervision in social gatherings/recreation programs and staff to minimize any close interaction with female residents. An additional care plan initiated 07/19/24 revealed Resident #1 demonstrated socially inappropriate behaviors: inappropriately touching staff.
Interventions included psychological counseling for psych/behavior management.Interview on 07/08/25 at 12:22 P.M. with CNA #233 revealed she worked with Resident #1. CNA #233 stated Resident #1 was sexually inappropriate, especially when staff changed him. Resident #1 would grab at staff; CNA #233 stated they tried to re-direct Resident #1, move his hand but he would not listen.
Interview with the Administrator on 07/08/25 between 1:35 P.M. and 3:11 P.M. stated the incident occurred in Resident #1's room while he was in bed.
During the interview, the Administrator stated Resident #2 was the perpetrator, not Resident #1.
However, no additional information was provided as to how this conclusion was reached.
Interview on 07/08/25 at 5:07 P.M. with CNA #233 revealed at the end of May (2025), she was cleaning Resident #1's buttocks due to him being incontinent. CNA #233 turned him over on his side and while she was washing him, Resident #1 began masturbating. CNA #233 also reported Resident #1 tries to touch CNA #233 inappropriately.
The CNA stated other CNAs had also reported Resident #1's sexual inappropriateness, but the facility had done nothing to address Resident #1's behavior. A telephone interview on 07/09/25 at 9:26 A.M. with CNA #217 revealed on 07/06/25, she was bringing Resident #1's roommate from the dining room to his room. As CNA #217 walked through the door, CNA #217 saw Resident #1 was lying in bed, Resident #1 had Resident #2 by the arm and had his hand on Resident #2's head/back of her neck making it go up and down on his penis.
The CNA stated she observed Resident #1 being forceful with Resident #2 and Resident #2 was trying to move to leave, as she was not sexual at all. CNA #217 told Resident #1 to let Resident #2 go, he was still holding her, then he let her go.
The CNA stated Resident #2 was blind, but she moved right away from Resident #1 once Resident #1 released his hands from her. CNA #217 stated she yelled, and LPN #283 came into Resident #1's room.
Interview on 07/09/25 at 10:07 A.M. with LPN #283 revealed on 07/06/25 in the morning, she was down the hall coming out of a different room when she heard CNA #217 call for her. LPN #283 entered Resident #1's room and saw CNA #217 moving Resident #2 away from Resident #1. Resident #2 was confused.
When LPN #283 walked into Resident #1's room, Resident #1 was in bed sitting straight up with a hospital gown on and his hand over his private part.
LPN #283 stated Resident #2 would not be forceful with anyone if she walked into a resident room.
Interviews on 07/08/25 between 12:48 P.M. and 12:55 P.M. with CNA #238, CNA #216, and Activity Director #203 revealed Resident #1 participated in activities and frequently sat in the dining room.
CNA #238, #216 and Activity Director #203 revealed Resident #1 never required supervision.
The facility identified Residents #23, #41, and #70 who resided on the same hall as Resident #1 and were independently mobile and had cognitive impairments.
This deficiency represents non-compliance investigated under Control Number OH00167346 (1381517).
This is an example of continued non-compliance from the survey dated 06/25/25.
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
including urinary tract infections.
Observe the resident for complications associated with urinary
investigated under Complaint Number 2581344 and Complaint Number 2574277.
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. On 08/01/25 there was a physician order for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a UTI for seven days. A progress note dated 08/02/25 at 3:07 P.M. completed by RN #333 revealed an alert from the pharmacy regarding the new order entered for Cipro 500 mg give one tablet by mouth two times a day for UTI for seven days had triggered possible drug to drug interactions.
Interview on 08/06/25 at 3:40 P.M. with the Director of Nursing (DON) revealed the DON reviewed Resident #20's Medication Administration Record (MAR) and confirmed Cipro was ordered on 08/01/25 and was scheduled to start on 08/02/25 at 9:00 P.M.
The DON confirmed from 08/02/25 through 08/06/25 for the scheduled doses at 9:00 P.M. the boxes all had a number nine; and documented Resident #20 received Cipro three of 10 doses on 08/03/25, 08/04/25, and 08/06/25 at 9:00 A.M. only.
Telephone interview on 08/06/25 at 4:55 P.M. with Certified Pharmacy Technician (CPHT) #515 with the DON present revealed the Cipro for Resident #20 was never sent because the pharmacist reached out for a drug interaction. CPHT #515 revealed the note stated an RN would clarify.
The pharmacy never received the response, so they never sent the Cipro.
The DON verified LPN #275 documented on the MAR she gave Resident #20 the Cipro from the prepackaged medications this A.M.
Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. On 08/07/25 there was an order by CNP #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days.
Flush peripherally inserted central catheter (PICC) line/midline/central line with 10 cubic centimeters (cc) normal saline (NS) before and after medication administration.
Interview on 08/07/25 at 10:39 A.M. with the DON and record review of the Pharmacy Communication request received 08/04/25 at 11:54 A.M. revealed the request stated to Please Respond.
Medication Cipro had a drug interaction with (medication) tizanidine.
Please consider changing the antibiotic to something else or hold all tizanidine while on this antibiotic.
The DON revealed she also gets emails from the pharmacy, but the recommendations also come through the fax.
The pharmacy also calls the nurses who need to update the physician with the pharmacy information.
The DON confirmed the pharmacy recommendation was not completed and revealed any nurse could do it.
This was an incidental finding discovered during the course of the complaint investigation.
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the facility policy titled Medication Administration dated 11/2017 revealed to administer the medications as ordered; the physician shall be notified of held medications.
This deficiency represents non-compliance investigated under Complaint Number 2574277 and Complaint Number 1381508 (OH00167560).
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact.
The assessment revealed Resident #20 required supervision or touch assistance with toileting hygiene. Resident #20 had no indwelling catheter or intermittent catheter noted on the MDS assessment. On 08/04/25 an order was obtained to remove indwelling catheter today (08/04/25) and straight catheterize every four to six hours. On 08/07/25 there was an order by Certified Nurse Practitioner (CNP) #514 to hold Cipro and start Ceftriaxone sodium solution reconstituted two grams use 2.0 grams intravenously in the morning for infection for three days and a urinalysis.
Interview on 08/07/25 at 10:16 A.M. with CNP #514 revealed she was not made aware until just a couple minutes ago that Resident #20 was not receiving the Cipro as ordered. CNP #514 stated, the facility never told her that Resident #20 not getting straight catheterized as physician ordered.
And when they do straight catheterization, the staff were obtaining more than 250 cc of urine left in the bladder and this was retention. CNP #514 confirmed retention (a condition in which a person is unable to empty their bladder completely) can cause a UTI. CNP #514 stated she was going to order an intravenous (IV) antibiotic now and more laboratory values including a urinalysis because Resident #20 did not receive the Cipro that was ordered. CNP #514 stated she was not happy with the facility and stated she had received a call from the hospital, and the urinalysis results returned from when she went to the ER on [DATE] and showed she had a UTI, that was why the Cipro was ordered.
Interview on 08/07/25 at 11:04 A.M. with Licensed Practical Nurse (LPN) #518 confirmed CNP #514 requested a urinalysis be obtained for Resident #20.
Record review and interview on 08/11/25 at 3:00 P.M. with Director of Nursing (DON) confirmed there were no urinalysis results in the medical record for Resident #20 for the urinalysis ordered 08/07/25.
The DON confirmed the urine was obtained on 08/07/25 and the urine was never sent to the laboratory.
The DON stated she did not know why the urine was never sent and confirmed it should have been obtained and sent per the CNP orders.
Telephone interview on 08/11/25 at 3:30 P.M. with CNP #514 confirmed she ordered a urinalysis on 08/07/25 for Resident #20 and revealed she was never notified the urinalysis was not completed as ordered.
This was an incidental finding discovered during the course of the complaint investigation.
366419 08/14/2025
Twinsburg Post Acute 8551 Darrow Road Twinsburg, OH 44087
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. Resident #20 had no indwelling catheter or intermittent catheter.
Review of the physician orders for Resident #20 revealed an order dated 03/31/25 to straight catheterize every six hours or urinary retention four times a day for urinary retention; an order dated 08/01/25 for Cipro (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day for a urinary tract infection (UTI) for seven days; and an order dated 08/04/25 for EBP use gown and gloves for high contact resident care including dressing,, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes and care of any device including trach, central line, tube feeding and catheter.
Observation on 08/07/25 at 11:38 A.M. revealed Licensed Practical Nurse (LPN) #518 and Unit Manager (UM) #350 straight catheterized Resident #20. UM #350 assisted Resident #20 back to bed and repositioned her legs.
Neither LPN #518 nor UM #350 donned an isolation gown. LPN #518 straight catheterized Resident #20 for a residual of 1,300 cubic centimeters (cc) during the second attempt.
LPN #518 then provided peri care for Resident #20. Resident #20 stated when staff straight catheterized her, they never wear isolation gowns. UM #350 stated nurses would only wear an isolation gown if the resident had an infection Interview on 08/07/25 at 12:21 P.M. with DON revealed staff should wear Personal Protective Equipment (PPE) for wound care, peri care, indwelling catheter, or when providing care for a specific reason. DON confirmed staff should wear an isolation gown when providing hands on care for Resident #20.
Review of the facility policy titled, Enhanced Barrier Precautions (EBP) revised February 2021 revealed EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO's) to residents. EBP refers to an infection control intervention designed to reduce the transmission of MDRO's during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that are unable to be covered or contained.
Indwelling medical devices include urinary catheters. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.
Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.
This was an incidental finding discovered during the course of the complaint investigation.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.