Twinsburg Post Acute

In the surveyor’s words

From the most serious findings on record at Twinsburg Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 10, 2026

  Based on observation, record review, staff and family interview, review of Geriatric Nursing clinical literature and review of the facility policy, the facility failed to develop and implement a comprehensive, individualized and effective fall management program to decrease Resident #32's risk of falls including a fall with injury. The facility also failed to ensure fall prevention interventions were in place for Resident #30, #32, #50, and #59. This affected four residents (#32, #30, #50, and #59) of five residents reviewed for accidents. The facility census was 53. […]

• Actual harm, isolatedF686Jan 5, 2026

  Based on medical record review, observation, interview, and policy review, the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers for Resident #26 and Resident #48. This affected two residents (Resident #26 and #48) of three residents reviewed for pressure ulcers.Actual harm occurred beginning on 12/08/25 when Resident #26 who was dependent on staff for activities of daily living, had current pressure ulcers and was at risk of developing additional pressure ulcers was found to have a new open wound area to the gluteal/upper thigh. […]

• Actual harm, isolatedF684Aug 14, 2025

  Based on record review, facility policy review and interview the facility failed to ensure Resident #2 received adequate, necessary and timely treatment following a fall with major injury. Actual Harm occurred on 05/20/25 when the facility failed to ensure Resident #2 was provided timely and necessary medical intervention/treatment following a fall. Approximately 12.5 hours after the fall occurred, Resident #2's daughter identified the resident was in excruciating pain. The resident was subsequently transported to the hospital where she was diagnosed with a fractured femur (as a result of the fall) requiring surgical repair. This affected one resident (#2) of three residents reviewed for incidents. The facility census was 70. […]

• Actual harm, isolatedF690Aug 14, 2025

  Based on observation, record review, facility policy review and interview with resident, facility staff, pharmacy staff and nurse practitioner the facility failed to implement a comprehensive and individualized plan of treatment for Resident #20 to ensure the resident was catheterized timely and as ordered for urinary retention and provided timely and necessary treatment for a urinary tract infection (UTI). Actual harm occurred on 07/28/25 when Resident #20 demanded to be transferred to the emergency room for uncontrolled pain. The resident was subsequently treated for urinary retention and a UTI. Prior to the hospitalization, the resident had physician orders to be straight catheterized for urine retention every six hours; however, this was not being completed as ordered. […]

• Actual harm, isolatedF684Jun 25, 2025

  Based on record review and interview, the facility failed to ensure a Nurse Practitioner (NP) or physician was contacted when Resident #8's family requested several times to speak with one of them. No explanation was provided for the family. This affected one (Resident #8) of three residents reviewed for ability to speak with the NP and physician. The census was 70. Findings Include: Review of the medical record for Resident #8 revealed an admission date of 06/10/25. Diagnoses included sepsis, acute respiratory failure, diabetes, dementia, cerebral infarction acute embolism and thrombosis of deep veins of unspecified upper extremity, and acute postprocedural pain. […]