Twinsburg Post Acute

Inspectors wroteBased 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 occurred on 01/25/26 when Resident #32, who had moderate cognitive impairment, a history of multiple falls and risk for falls and history of urinary tract infection (UTI) sustained an unwitnessed fall resulting in an orbital fracture. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain a timely urine sample for a physician ordered urinalysis for a resident exhibiting signs and symptoms of a urinary tract infection (UTI). The facility also failed to ensure timely physician notification of the diagnostic results indicating positive findings consistent with a UTI. The failure to promptly initiate diagnostic testing and follow acceptable standards of nursing practice resulted in a delay in identifying and treating the resident's potential infection placing the resident at risk for worsening infection and avoidable decline. This affected one (Resident #32) of three residents reviewed for timely obtaining and reporting physician ordered labs. The facility census was 53.

Inspectors wroteBased on record review, medication administration observation, staff interview, insulin pen instruction manual review and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice to maintain a medication error rate of less than five percent (5%). Observation during medication administration revealed two errors were observed of 39 opportunities with a 5.12% error rate. This affected two (Residents #7 and #32) of four residents observed for medication administration. The facility census was 53.

Inspectors wroteBased on observation of medication administration, interview, record review, review of insulin pen instruction manual and facility policy review, the facility failed to ensure Resident #7 was free from a significant medication error when the resident received an incorrect dose of insulin as ordered by the physician. This affected one (Resident #7) and had the potential to affect four additional (Residents #1, #6, #24, and #60) identified by the facility as also receiving insulin pen injections. The facility census was 53.

Inspectors wroteBased on observation of medication administration, record review, staff interview and facility policy review, the facility failed to ensure accurate documentation of medication administration in accordance with professional standards of practice. This affected one (Resident #32) of four residents reviewed for medication administration. The facility census was 53.

Inspectors wroteBased 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. The facility failed to complete a comprehensive wound assessment of the area, failed to provide appropriate/adequate interventions, and failed to ensure the facility wound physician and wound nurse were timely notified of to prevent the deterioration of the of the wound. [...]

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to maintain the most current and accurate advance directive in the resident record. This affected one resident (#71) of three residents reviewed for death. Facility census was 65.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to provide timely incontinence care for Resident #16 and #20. This affected two residents (Residents #16 and #20) of three resident reviewed for incontinence care. The facility census was 65.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to ensure Resident #62 was monitored and treated timely for a change in condition after a fall. This affected one resident (Resident #62) of three residents reviewed for falls. The facility census was 65.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to maintain enhanced barrier precautions (EBP) and handwashing during resident care. This affected three residents (Resident #20, #48 and #26) of three observed for enhanced barrier precautions.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, record review, review of a facility Self-Reported Incident (SRI) report, facility policy review and interview, the facility failed to provide residents who have wandering and/or sexual aggressive behaviors with adequate supervision. This affected two residents (#1 and #2) and the potential to affect three residents (#23, #41, and #70) who the facility identified to be independently mobile, confused and residing in the same hall as Resident #1.

Inspectors wroteBased on observation, interviews with resident, staff and Certified Nurse Practitioner (CNP), record review, review of insulin administration guidelines, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected four (#7, #11, #20, and #68) of six residents reviewed for medication administration. The facility census was 70.

Inspectors wroteBased on resident, family, staff and certified nurse practitioner (CNP) interviews, record review, and review of the facility policy, the facility failed to timely notify the physician/CNP when physician orders were not completed and pharmacy irregularities on a antibiotic and notify a resident's representative of an incident and a room change involving the resident. This affected two (Residents #1 and #20) of three residents reviewed for notification of change. The facility census was 70. 1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and retention of urine. 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 noted on the MDS assessment. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure wound care was completed as per the physician orders for one resident, Resident #57 of three residents reviewed for wound care. The facility census was 70.

Inspectors wroteBased on record review and interviews with staff and pharmacy, the facility failed timely respond and act upon the pharmacy's notification regarding irregularity with a new order to start an antibiotic. This affected one (#20) of one resident reviewed for pharmacy services.

Inspectors wroteBased on record review and interviews with staff, the facility failed to timely obtain a urinalysis ordered by the physician/certified nurse practitioner (CNP). This affected one (#20) of one resident reviewed for laboratory services.

Inspectors wroteBased on observation, resident and staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff wore personal protective equipment (PPE) for a resident on Enhanced Barrier Protection (EBP). This affected one (#20) of one resident reviewed for infection control. The facility census was 70.

Inspectors wroteBased 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. The resident was discharged to the hospital 06/15/25. Review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 06/14/25, revealed Resident #8 had severely impaired cognition. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate supervision was provided to prevent Resident #7 from leaving the facility property unsupervised. This affected one (Resident #7) of four residents reviewed for leave of absence (LOA). The facility census was 70.

Inspectors wroteBased on observation, interview, review of the manufacturer's instructions for use of Insulin Glargine - yfgn and review of facility policy, the facility failed to ensure medications were administered according to physician's orders for Residents #22, #38, and #54. This affected three residents (#22, #38 and #54) of three residents reviewed for insulin administration and had the potential to affect ten additional residents (#2, #3, #5, #12, #16, #25, #26, #34, #44 and #45) identified by the facility with physician's orders for insulin. The facility census was 65.

Inspectors wroteBased on review of electronic medical records (EMR), hard charts and binders (utilized during transition of EMR) and interviews with staff, the facility failed to maintain complete, accurate, and readily accessible records for Residents #6, #17, #22, #51 and #53. This affected five (#6, #17, #22, #51 and #53) of seven resident records reviewed for complete and accurate medical records. The facility census was 65.

Inspectors wroteBased on medical record review, interview and review of the facility policy, the facility failed to ensure Resident #22's resident representative was informed of a medication change and a fall. This affected one resident (#22) of three residents reviewed for changes in condition. The facility census was 65.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to implement baseline care plans within 48 hours after admission for Resident #22, Resident #38 and Resident #62. This affected three residents (#22, #38, and #62) of three residents reviewed for baseline care plans. The facility census was 65.

Inspectors wroteBased on medical record review, interview, and review of facility policy the facility failed to ensure a comprehensive care plan was developed and implemented for Resident #22. This affected one resident (#22) of three residents reviewed for care plans. The facility census was 65.

Inspectors wroteBased on medical record review, interview and review of the facility policy, the facility failed to ensure Resident #22's fall was thoroughly investigated and failed to ensure fall interventions were in place to prevent a subsequent fall. This affected one resident (#22) of three residents reviewed for falls. The facility census was 65.

Inspectors wroteBased on record review, observation, interview, manufacturer's instructions for use of Insulin Glargine - yfgn and review of the facility policy, the facility failed to ensure a medication error rate of less than five percent. This affected three residents (#4, #38, and #54) of five residents observed for medication administration and yielded a 13.79 percent medication error rate. The facility census was 65.

Inspectors wroteBased on observation, interview, review of the facility policy and review of the Centers for Disease Control and Prevention (CDC) website's Considerations for Blood Glucose Monitoring and Insulin Administration summary of recommendations for blood glucose monitoring, the facility failed to properly clean and disinfect the blood glucose monitor (BGM) between resident use. This affected one resident (Resident #54) of five residents observed during medication administration and had the potential to affect three additional residents (#5, #12 and #38) who receive blood sugar monitoring in the 200 Mid Hall. The facility census was 65.

Inspectors wroteBased on review of a video recording, staff interview, record review, and review of the facility policy, the facility failed to treat a resident with respect and dignity. This affected one (Resident #72) of three residents reviewed for dignity and respect. The facility census was 69.

Inspectors wroteBased on review of a video recording, staff interviews, record review, and review of the facility policy, the facility failed to safely transfer a resident per the care plan, failed to timely assess the resident status post fall, and document the fall in the medical record. This affected one (Resident #72) of three residents reviewed for falls. The facility census was 69.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to ensure physician orders were followed to obtain blood pressure reading prior to medication administration for Resident #70. This affected one resident (#70) of four residents reviewed for medication administration. The facility census was 71.

Inspectors wroteBased on observation, interview, review of the medical record and facility policy the facility failed to ensure timely incontinence care was provided for Resident #70. This affected one resident (#70) of three residents reviewed for incontinence care. The facility census was 71.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #28's physician, power-of-attorney (POA) and hospice service were notified in a reasonable timely manner for a change of condition, and failed to ensure Resident #28's POA was notified of new physician's orders as well as radiology results. This affected one (Resident #28) of three residents reviewed for a change in condition and notification. The facility census was 78.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #28's pain medications were administered as ordered. This affected one (Resident #28) of five residents reviewed for medication administration. The facility census was 78.

Inspectors wroteBased on record review and interviews, the facility failed to ensure documentation in the medical record was complete and accurate. This affected two (Residents #28 and #55) of eight residents reviewed for documentation of medication and treatment administration. The facility census was 78.

Inspectors wroteBased on closed record review and interview, the facility failed to prevent a significant medication error for Resident #50 resulting in an acute change in condition requiring hospitalization. Actual Harm occurred on 05/17/24 when Resident #50, who had diagnoses of heart failure and chronic bilateral lower extremity lymphedema, was transferred to the hospital due to significant shortness of breath after not receiving the physician ordered diuretic medication, Torsemide following his admission to the facility on [DATE].

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure medications were administered without error. This affected two residents (#32 and #79) of four residents observed during 29 medication opportunities with seven medication errors. The medication administration error rate was 24.13 %. The facility census was 80.

Inspectors wroteBased on record review and interview the facility failed to ensure staff documented Resident #32's shower/bath accurately. This affected one out of three residents reviewed for activity of daily living needs. The facility census was 80.

Inspectors wroteBased on observation and interview the facility failed to ensure staff washed their hands appropriately to prevent possible cross contamination of germs during Resident #32's and Resident #79's medication administration, failed to ensure staff wore appropriate personal protective equipment (ppe) prior to administering insulin subcutaneously and eye drops to Resident #79, and failed to ensure Resident #79's eye drops were not contaminated prior to administering the eye drops to Resident #79. This affected two out of four residents observed for medication administration. The facility census was 80.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to serve foods in a sanitary manner to prevent contamination. This had the potential to affect all 83 residents who received food from the kitchen, except Residents #37, #59, and #387 who had orders for nothing-by-mouth (NPO). The facility census was 86.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to assure staff were competent and compliant with medication administration documentation, physician notification, and use of a glucometer. This affected four residents (#390, #17, #45, and #64) of six residents reviewed during medication administration. The facility census was 86.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medication per the physician order for four residents, Resident #7, #390, #17, and #64 of six residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on observation, medical record review, interview, and facility policy review, the facility failed to ensure medications for Residents #66, #384, and #389 were properly prepared for administration and failed to ensure medications for Resident #238 were stored as required. This affected four residents (#66, #384, #389, and #238) of nine residents reviewed medication storage. The facility census was 86.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had advanced directives in their medical records. This affected two residents (#53 and #396) of two reviewed for advance directives. The facility census was 86.

Inspectors wroteBased on record review and interview the facility failed to provide evidence they notified the resident or representative of non-coverage in writing on the Notice of Medicare Non-Coverage (NOMNC) for Residents #9, #28, and #239. This affected three residents (#9, #28, and #239) of three residents reviewed for liability notices. The facility census was 86.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to have a quarterly care conference with Resident #66 and his family. This affected one resident (#66) of three residents reviewed for care plan meetings. The facility census was 86.

Inspectors wroteBased on observation, interview, record review, and review of the facility policies, the facility failed to assist Resident #66 with showers or bed baths as preferred and failed to provide timely incontinence care to Resident #390. This affected two residents (#66 and #390) of five residents reviewed for activities of daily living. The facility census was 86.

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to serve meals at an appropriate temperature. This affected one resident (#49) of five residents observed for meals. The facility census was 86.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to follow Resident #396's diet orders. This affected one resident (#396) of three residents reviewed for nutrition. The facility census was 86.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to maintain infection control practices and encourage fluids for Resident #66. This affected one resident (#66) of three residents reviewed for infection control. The facility census was 86.

Inspectors wroteBased on observation, menu extension review and interview, the facility failed to follow the menu. This had the potential to affect all residents who received meals from the kitchen except Residents #18, #26 and #50 who were ordered nothing-by-mouth (NPO). The census was 82.

Inspectors wroteBased on observation, policy review, diet order report review, and interview the facility failed to ensure meals were served at a palatable temperature. This affected five residents (Residents #29, #67, #51 and one anonymous resident) and had the potential to affect all residents who received meals from the kitchen except Residents #18, #26 and #50 who were ordered nothing-by-mouth (NPO). The census was 82.

Inspectors wroteBased on observation, menu extension review, diet order report review and interview, the facility failed to ensure Resident #8 was served nectar-thickened liquids according to the physician order. This affected one resident (Resident #8) and had the potential to affect two additional residents (Residents #65 and #82) who were ordered thickened liquids. The census was 82.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure fall prevention interventions were implemented for Resident #14. This affected one resident (Resident #14) of three residents reviewed for falls. The facility census was 86.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, emergency room documentation, emergency medical services (EMS) run sheet and interviews, the facility failed to prevent significant medication errors when medications prescribed for Resident #35 were administered to Resident #74 in error. This affected one resident (#74) of three residents reviewed for medication administration. The census was 73. Actual harm occurred on 11/03/23 at approximately 7:15 P.M. [...]

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 71 out of 73 residents who ate meals from the facility's kitchen. Resident #43 and #45 were identified as receiving nothing by mouth. The facility census was 73. Findings Include: Observation of the tray line on 11/02/23 from 11:50 A.M. through 12:50 P.M. revealed the orange chicken was 150 degrees Fahrenheit (F) and the egg roll was 141 degrees (F). Completion of a test tray and interview on 11/02/23 at 1:00 P.M. with Registered Dietitian, Licensed Dietitian (RD, LD) #280 revealed the orange chicken was 107 degrees F, the egg rolls were 116 degrees F, Lo Mein noodles were 121 degrees F, and the cold drink was 57 degrees F. The orange chicken, egg rolls and Lo Mein noodles were lukewarm and unsavory. [...]

Inspectors wroteBased on observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected 85 residents receiving meals from the kitchen as three residents (Residents #16, #77 and #89) were ordered nothing-by-mouth. The facility census was 88 residents.

Inspectors wroteBased on observation, interview and menu spreadsheet review, the facility failed to serve palatable meals at appetizing temperatures. This affected 85 residents receiving meals from the kitchen as three residents (Residents #16, #77 and #89) received nothing-by-mouth. The facility census was 88 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications in the medication storage room were not expired. This had the potential to affect all 69 residents residing on the second floor. The facility census was 88. Findings Include: Observation on [DATE] at 4:43 P.M. of the medication storage room on the second floor revealed six bottles of multivitamins with an expiration date of 01/2022, four bottles of enteric coated aspirin 81 milligram (mg) with an expiration date of 01/2022, and two bottles of Enulose 10 mg per 15 milliliters (ml) with an expiration date of 12/2021 Interview on [DATE] at 4:43 P.M. with Registered Nurse (RN) #419 verified the above observations.

Inspectors wroteBased on observation and interview the facility failed to clean the glucometer after testing the blood sugar of diabetic residents. This affected five residents (Residents #12, #25, #26, #41, and #51) of 17 residents receiving medications from the medication cart. The facility census was 88. Findings Include: Review of the medical record for Residents #12, #25, #26, #41, and #51 revealed all five residents were insulin dependent diabetics. Observation on 04/06/22 at 8:47 A.M. revealed Registered Nurse (RN) #409 entered Resident #25's room to check her blood sugar. After obtaining the blood sugar RN #409 returned to the medication cart and placed the glucometer (an instrument used to determine a resident's blood sugar) on top of the medication cart. [...]

Inspectors wroteBased on observation, interview and medical record review, the facility failed to develop and implement a dental plan of care for Resident #103 and failed to develop a plan of care related to safe positioning for Resident #15. This affected two of four residents reviewed for care plans. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 04/13/17 and a readmission date of 02/07/18. Diagnoses included malignant neoplasm of prostate (cancer), obstructive and reflux uropathy (a blockage in the urinary tract), morbid obesity, secondary unspecified malignant neoplasm of intrapelvic lymph nodes, essential primary hypertension, atherosclerotic heart disease, chronic diastolic heart failure, type 2 diabetes, schizophrenia, and other recurrent depressive disorders. [...]

Inspectors wroteBased on interview, record review, and policy review the facility failed to ensure neurological checks were completed for Resident #62 post fall. This affected one of five residents reviewed for falls. The facility census was 88. Findings Include: Review of Resident #62's medical record revealed an admission date of 02/28/22 and diagnoses including heart failure, sarcoidosis, malignant neoplasm of lung, syncope and collapse, transient cerebral ischemic attack, dysphagia, cognitive communication deficit, cardiac arrest, elliptic seizures and mild-protein calorie malnutrition. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively impaired, had inattention, disorganized thinking and altered level of consciousness. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure fall interventions were in place for Resident #15. This affected one of five residents reviewed for falls. The facility census was 88. Findings Include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, right knee contracture, arthritis, high blood pressure, and depression. Review of the resident's care plans revealed she was at risk for falls due to impaired mobility, impaired balance, and a history of falls. Interventions to prevent falls included to use body pillows in bed and therapy evaluation and treatment per orders. Further review of the medical record revealed on 09/04/21 at 10:31 A.M. Resident #15 had a fall. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure Resident #55's medications were reviewed monthly by a licensed pharmacist. This affected one of four residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on observation and interview, the facility failed to ensure Resident #18, Resident #56, and Resident #58 had clothing protectors during all meals. This affected three (Resident #18, Resident #56, and Resident #58) of four residents observed requiring a clothing protector during meal service.

Inspectors wroteBased on observations and interview, the facility failed to ensure Resident #30, Resident #53, Resident #60, and Resident #92 were supervised while eating during meal services. This affected all four (Resident #30, Resident #53, Resident #60, and Resident #92) of four residents observed eating without supervision in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served the correct portion size of pureed dinner roll. This affected all five (Resident #86, Resident #59, Resident #37, Resident #66, and Resident #309) of five residents that were on a dysphagia or pureed textured diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable sound levels for Resident #65. This affected two (Residents #65 and #39) of six residents reviewed for comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided to a resident dependent for activities of daily living (ADLs). This affected one (Resident #12) of three residents reviewed for activities of daily living. The facility identified 47 residents as being dependent for ADLs.

Inspectors wroteBased on record review and interview, the facility failed to ensure medication was administered as ordered for one resident (Resident #79) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure labeling and storage of medication. This affected seven of 102 residents residing in the facility (Residents #1, #202, #203 #14, #70, #81, and #92).

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure staff provided care in a manner to prevent the spread of infection. This affected one (Resident #28) for maintenance of a urinary catheter and during catheter care of one resident reviewed for urinary catheters and one (Resident #64) during incontinence care of one resident reviewed for urinary tract infections.