Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Pomeroy, Llc during CMS and state inspections, most recent first.
Hand hygiene and PPE use were not completed appropriately during observed resident care. A CNA failed to wear a gown while emptying a catheter drainage bag for a resident on EBP, and an LPN and CNA were observed missing required hand hygiene during PEG tube medication administration, wound care, and nephrostomy tube emptying. The residents involved had indwelling devices and, in one case, wounds and MASD; the DON acknowledged the gown was omitted during catheter care.
A resident with severely impaired cognition had no current code status documented in the EMR or paper chart, and the baseline care plan also lacked this information. An RN initially could not locate the code status and said she would have to search the EMR, documents tab, and paper chart; she later found an IPOST on the ADON’s desk showing CPR with limited additional interventions, but it was signed only by the ADON and not by the resident, legal rep, or physician. The ADON said she was trying to get the resident’s daughter to sign the form and stated that if no code status was listed, the resident was considered full code.
Failure to complete Significant Change MDS assessments for two residents. One resident with severe cognitive impairment and major functional decline progressed from walker-assisted mobility to wheelchair use and mechanical lift transfers, while staff stated the resident had not walked for months. Another resident with a BIMS of 13 sustained a fibular neck fracture after a fall, remained painful and non-weight bearing, and continued to require a mechanical lift for transfers, but no timely SCSA was set up after the change in status was determined.
Failure to follow insulin hold parameters for a resident with DM and long-term insulin use. The resident’s order directed staff to give Novolog 28 units BID and hold it if BG was below 120 mg/dl, but the TAR showed multiple doses were given when BG was below that threshold. The ADON acknowledged the documentation, and the DON stated the facility did not have a policy for following physician orders.
Failure to provide ROM and restorative services for two residents. One resident with severe cognitive impairment and declining mobility had care plan changes from walker use to a sit-to-stand lift, but staff documented ambulation tasks as not applicable or noted refusals, and staff gave conflicting accounts of whether he still walked. Another resident with BIMS 0 and diagnoses including scoliosis and Rett’s syndrome had no restorative therapy, ROM, or therapy screening since admission, despite the family requesting therapy to help prevent contractures. The DON stated restorative reviews were not being completed appropriately and the Administrator said there was no policy for ROM or restorative therapy.
Two residents experienced medication administration errors, including missed doses, incorrect dosages, and unattended medications left on a food tray. One resident with severe cognitive and physical impairments had three medication errors involving seizure medication, while another cognitively intact but physically dependent resident had her medications left unattended by agency staff. Staff interviews confirmed lapses in following proper medication administration protocols.
Temporary nurses and CNAs were assigned to care for residents without receiving proper orientation or training. Several agency staff reported not being given education or checklists before working independently, and a resident with recent hospitalization had to instruct a CNA on her care needs. The facility could not provide documentation that required orientation was completed for all temporary staff.
The facility did not accurately submit direct care staffing data to CMS, resulting in reports that failed to reflect actual licensed nursing coverage. Although nurses were present according to schedules and timesheets, the PBJ submissions showed inconsistent and incorrect staffing levels due to an unorganized process managed by a third-party vendor.
A resident with multiple diagnoses and no cognitive impairment experienced a fall resulting in a bruise, but staff did not notify the physician or family as required, nor did they complete weekly monitoring documentation for the injury.
A resident with multiple diagnoses and no cognitive impairment was transferred to the hospital on several occasions and readmitted each time, but the facility failed to notify the LTC Ombudsman as required. Review of documentation and staff interviews confirmed that the resident's name was missing from the notification forms, resulting in a deficiency in regulatory compliance.
A resident with severe cognitive and physical impairments, including Rett's Syndrome and total dependence on staff, was observed using a seat buckle in her wheelchair. The care plan did not address the use or monitoring of the seat buckle, and staff failed to document or define interventions related to its use, despite facility policy requiring comprehensive care planning.
A resident with diabetes had blood glucose readings outside physician-ordered parameters on multiple occasions, but staff failed to notify the provider as required. Despite facility policy and care plan directives, documentation and staff interviews confirmed that abnormal results were not reported to the physician.
A resident with chronic edema did not receive prescribed compression stockings as ordered, despite staff documentation indicating otherwise. The resident, who was cognitively intact and independent but needed help with the stockings, was observed without them during the day, and staff cited the stockings were wet and not applied. The facility lacked a specific edema management policy, and staff were expected to follow physician orders.
A resident was given 40 mg of pantoprazole instead of the prescribed 20 mg daily dose over several weeks. The error was discovered but not documented, and the family and physician were not informed. The facility lacked policies on ensuring correct medication doses and notifying family and physicians of errors.
A resident with chronic respiratory failure and COPD experienced multiple episodes of respiratory distress due to the facility's failure to update her care plan in a timely manner. The care plan did not reflect a change in her BiPAP machine order from 2 liters to 6 liters of oxygen, leading to significant drops in her oxygen levels and severe respiratory distress.
The facility failed to follow physician's orders for two residents, leading to medication and treatment errors. One resident received the wrong dose of pantoprazole for nearly a month, while another experienced severe respiratory issues due to incorrect BiPAP settings. The facility lacked proper incident reporting and policies to ensure adherence to physician's orders.
A resident fell out of his wheelchair and sustained a foot injury, but the facility failed to timely assess and intervene. Despite the resident's complaints of increased pain and decreased movement, staff did not promptly contact the doctor, leading to a delay in diagnosing fractures. The facility lacked specific policies on change in condition and relied on standards of care and regulations.
The facility failed to provide post-dialysis assessments for a resident with chronic kidney disease and other conditions. The resident's chart lacked vital signs and assessments on multiple dates, and staff interviews revealed inconsistencies in completing these assessments as per the facility's policy.
Hand Hygiene and EBP PPE Failures During Resident Care
Penalty
Summary
The facility failed to complete appropriate hand hygiene for 3 of 4 residents observed and failed to apply a gown during catheter care for a resident on Enhanced Barrier Precautions (EBP). The facility had a census of 24 residents. Review of the facility policy showed hand hygiene was required before and after glove use, before aseptic technique or handling an invasive medical device, after touching a resident or contaminated surfaces, and when moving from a soiled body site to a clean body site on the same resident. Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and that the resident had an indwelling catheter, chronic kidney disease stage 3A and 3B, and was on EBP due to risk for MDRO colonization related to catheter placement. During observation, a CNA performed hand hygiene, applied gloves, but did not apply a gown before entering the room and emptying the catheter drainage bag. The CNA used a cylinder placed inside a trash bag on the floor to collect 750 mL of urine, cleansed the catheter drainage valve with alcohol swabs, emptied the cylinder into the toilet, rinsed the cylinder, and then performed hand hygiene. The DON later acknowledged staff needed to wear the appropriate PPE when emptying the catheter drainage bag and stated the CNA reported forgetting to wear a gown during catheter care. Resident #16’s MDS documented a BIMS of 0 and a PEG tube for nutritional supplement. During PEG tube medication administration, an LPN applied a gown and gloves but completed no hand hygiene before the procedure and no hand hygiene after removing gloves and gown. Resident #19’s MDS documented a BIMS of 14, skin tears, MASD, and a nonsurgical dressing; during wound care, an LPN applied wound wash to gauze without gloves, entered the room, donned gown and gloves without hand hygiene, removed and reapplied gloves during the dressing change without hand hygiene, and left the room before completing hand hygiene at the nurses’ station. Resident #20’s MDS documented a BIMS of 15 and a nephrostomy tube; during emptying of the nephrostomy tube, a CNA applied gown and gloves but did not complete hand hygiene before handling the drainage equipment, then emptied urine, cleansed the graduate, removed PPE, and completed hand hygiene afterward.
Code Status Not Available in Resident Record
Penalty
Summary
The facility failed to ensure that Resident #10’s current code status was available in the resident record. Resident #10’s MDS showed a BIMS score of 05, indicating severely impaired cognition, and documented diagnoses of hypertension, thyroid disorder, arthritis, Alzheimer’s disease, and non-Alzheimer’s disease. The baseline care plan did not include code status documentation, and both the electronic medical record and paper chart lacked documentation of the resident’s code status when reviewed by staff and surveyors. During interview, an RN stated she would normally check the electronic medical record header for code status, then the documents tab for an IPOST, and then the paper chart if needed. She verified that Resident #10’s code status was not documented in the electronic record or paper chart and said having to search for it would slow response time if CPR were needed. The RN later found an IPOST on the ADON’s desk showing CPR with limited additional interventions, but it was completed and signed by the ADON only and was not signed or dated by the resident, legal representative, or a physician. An email showed the ADON had asked the resident’s daughter to sign the IPOST so the physician could sign it and the code status could be entered correctly. The ADON reported she had been trying to obtain the daughter’s signature, stated the resident’s daughter lived out of state, and said that if a code status was not listed the resident was considered full code.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for two residents after major changes in condition were documented in the clinical record. One resident had severe cognitive impairment on the MDS, with care plan revisions showing a change from requiring one staff assist with a walker for transfers and ambulation to requiring two staff with a mechanical sit-to-stand lift. The record also showed a progression from partial/moderate assistance with walking and use of a walker and wheelchair to no longer attempting walking and using only a wheelchair. Staff interviews indicated the resident did not walk and had not walked for months, but the restorative task had not been removed or addressed through a significant change assessment. A second resident had a BIMS score of 13 and diagnoses including viral hepatitis, diabetes mellitus, chronic pain syndrome, and cerebral infarction. After a fall in which the resident was lowered to the floor when the right knee gave out, the resident was found to have an acute non-displaced fracture of the fibular neck and was placed on non-weight bearing status until orthopedic follow-up. After the orthopedic visit, the resident was ordered weight bearing as tolerated, but progress notes documented continued significant pain, continued non-weight bearing behavior, and ongoing use of a mechanical lift for transfers with assistance from two staff members. The resident’s care plan was revised to place ambulation on hold, use a wheelchair, use a mechanical lift for transfers, and later allow a mechanical sit-to-stand lift per therapy recommendations. The MDS tracking page showed no Significant Change in Status MDS had been set up within 14 days after the change was determined. The DON acknowledged that a Significant Change in Status MDS should have been completed, and the ADON reported being told she could either change the quarterly MDS or open a new significant change assessment.
Failure to Follow Insulin Hold Parameters
Penalty
Summary
The facility failed to provide insulin administration according to the physician’s order for Resident #15, who had diagnoses of diabetes mellitus and long term use of insulin and a BIMS score of 14 indicating intact cognition. The care plan identified the resident as at risk for altered blood glucose levels and directed blood sugars to be checked per order, with observation for medication side effects and effectiveness. The physician order dated 6/22/25 directed staff to administer Novolog FlexPen 28 units subcutaneously twice daily and to hold the insulin if the blood sugar was less than 120 mg/dl. Review of the March 2026 through May 2026 TAR showed multiple instances in which Novolog 28 units was administered even though the blood sugar was below 120 mg/dl, including readings of 98, 103, 77, 113, 114, 111, and 87 mg/dl. On 5/13/26, the ADON acknowledged the insulin was documented as given when the blood sugar was below the ordered threshold and stated she would expect the physician order to be followed. The DON stated the facility did not have a policy regarding following physician orders and that they follow standards of care.
Failure to Provide ROM and Restorative Services
Penalty
Summary
The facility failed to provide treatment and services to maintain or improve range of motion for 2 residents with decreased mobility and limited ROM. Resident #5 had severe cognitive impairment, had previously been cared for with walker-assisted transfers and ambulation, and later had care plan revisions changing transfers and ambulation to a mechanical sit-to-stand lift with 2 staff. The EHR also showed an ambulation/restorative task for walking with assistance to and from meals, but staff repeatedly documented the task as not applicable or recorded resident refusal on multiple dates. Staff interviews showed conflicting understanding of Resident #5’s mobility status, with some staff stating he had not walked in months and that they documented not applicable because he no longer walked, while others stated they were unsure about restorative expectations. Resident #16 had a BIMS of 0 and diagnoses including scoliosis, cramp and spasm, developmental disorder of scholastic skills, and Rett’s syndrome. The resident’s mother stated she wanted therapy to prevent or decrease the possibility of contractures. Review of the EHR showed no restorative therapy, ROM, or therapy screening since admission. Staff interviews confirmed that Resident #16 was not receiving restorative therapy or ROM, and one CNA stated she would stretch the resident’s arms during dressing but did not know whether she was supposed to do so. Therapy staff stated quarterly screens were expected, but also acknowledged uncertainty about how restorative plans were handled at the facility and that no restorative plan had been developed there during their time working with the facility. The DON stated the facility got restorative plans from therapy and that the restorative review process had not been completed appropriately. The DON also stated the ADON oversaw restorative programs, that the MDS reimbursement specialist would retrain the ADON on restorative reviews, and that the facility had residents who were not on therapy but would benefit from a restorative plan. The Administrator stated the facility did not have a policy for ROM or restorative therapy.
Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered for two residents, resulting in multiple medication errors. For one resident with severe cognitive impairment, total dependence on staff, and a history of seizures, there were three documented medication errors within a five-week period. These included a missed evening medication and feeding, administration of an incorrect nighttime dose during the morning, and administration of an incorrect nighttime dose. Staff interviews confirmed that medications were forgotten or given in the wrong dosage, and that medication administration was inconsistent, particularly during holiday weekends and when using different medication delivery methods (bottle versus pre-filled syringes). Another resident, who was cognitively intact but physically dependent, had her cup of medications left unattended on a food tray by agency staff. The medications were discovered by kitchen staff after the tray was removed from the resident's room, and subsequently returned to the resident by nursing staff. The facility confirmed that no residents had been assessed as capable of self-administering medications unsupervised, and that nurses were expected to follow the five rights of medication administration.
Failure to Provide Orientation and Training for Temporary Nursing Staff
Penalty
Summary
The facility failed to ensure that temporary nurses and CNAs received proper orientation and training before independently caring for residents. Multiple agency staff members, including CNAs and an RN, reported that they did not receive an orientation or education prior to working with residents. One CNA stated it was her second day at the facility and she had not been given an orientation or education checklist. Another CNA described working an overnight shift alone and attempting to transfer a resident without a mechanical lift, as she was unaware of the resident's needs. The RN recalled only receiving a brief tour and not a complete orientation or signed checklist. These accounts were corroborated by interviews and observations conducted by surveyors. A resident with a history of dialysis and recent hospitalization expressed concern about the lack of knowledgeable staff, stating that she had to instruct a CNA on how to assist with her catheter and toileting needs. The facility's administration acknowledged that orientation checklists were generally kept on the DON's desk, but could not provide documentation for the specific staff in question. The facility had an agency staff orientation checklist outlining required topics, but there was no evidence that all temporary staff had completed or signed off on this orientation prior to providing care.
Failure to Accurately Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for the first quarter of fiscal year 2025. The PBJ Staffing Data Report indicated multiple dates where there was a lack of licensed nursing coverage for 24 hours per day, despite a review of nursing schedules and timesheets showing that nurses were on duty on those dates. The Administrator confirmed that the PBJ report was being managed by a third-party entity and described the process as unorganized and confusing, resulting in incorrect submissions, such as overreporting nurse staffing on some days and showing no nurses on others. The facility's policy required timely and accurate submission of staffing data, but this was not followed, leading to the deficiency.
Failure to Notify Physician and Family After Resident Fall and Skin Injury
Penalty
Summary
Staff failed to notify both the physician and the family of a resident after a fall that resulted in a skin condition. Clinical record review showed that a nurse documented a bruise on the back of the resident's right leg, measuring 2 cm by 4 cm and described as yellow, green, and purple. The progress notes did not indicate that the physician or family had been informed of the injury. Additionally, the facility did not complete the required skin sheet to monitor the bruise on a weekly basis as per their policy. The resident involved had diagnoses of schizophrenia, depression, and orthostatic hypotension, and was assessed as having no cognitive impairment. Facility policy required that any new skin alteration be assessed, documented, and reported to the physician, with appropriate treatment orders and care plan updates. However, these steps were not followed in this case, as the required notifications and documentation were not completed.
Failure to Notify LTC Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding a resident who was transferred to the hospital on multiple occasions. Clinical record review and staff interviews confirmed that the required notification was not completed for this resident, who had diagnoses including quadriplegia, anxiety, depression, and chronic pain, and was assessed as having no cognitive impairment. Documentation showed the resident was transferred to the hospital three times and subsequently readmitted to the facility each time, with corresponding entries in the progress notes, census records, and MDS assessments. Despite these transfers, review of the facility's Notice of Transfer Forms for the relevant months did not include the resident's name, indicating the ombudsman was not notified as required. Interviews with facility staff, including the Nurse Consultant and Administrator, confirmed the omission, with the Administrator noting that the resident's name did not appear on the electronic report used for notifications. This failure to notify the ombudsman represents a deficiency in meeting regulatory requirements for resident transfers.
Failure to Include Wheelchair Seat Buckle Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was observed using a seat buckle in her wheelchair. The care plan did not include a focus area or interventions for monitoring the use of the seat buckle, nor did it define specific interventions related to its use. Staff utilized the seat buckle, but the care plan lacked documentation and guidance regarding this device. This omission was confirmed by a clinical specialist, who agreed that the lap strap should have been added to the care plan. The resident involved was nonverbal, rarely or never understood, and unable to participate in cognitive assessments. She was totally dependent on staff for all activities of daily living, had significant upper and lower extremity impairments, and used a wheelchair for mobility. Her diagnoses included diabetes mellitus, aphasia, seizure disorder, malnutrition, and Rett's Syndrome, which contributed to severe muscle movement disability and loss of purposeful hand skills. Despite her complex needs and the use of a seat buckle, the care plan did not address this intervention, contrary to facility policy requiring comprehensive, person-centered care plans.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
Staff at the facility failed to follow physician orders regarding blood glucose monitoring for one resident with diabetes mellitus and other comorbidities. The physician had ordered blood glucose checks four times daily, with instructions to notify the provider if levels exceeded 400 mg/dL or dropped below 60 mg/dL. Over a three-month period, the resident's blood glucose readings fell outside these parameters on eight occasions, but there was no documentation that the physician was notified as required. The resident's care plan also specified that abnormal blood glucose levels should be reported to the physician. Review of the electronic chart and interviews with staff confirmed that notifications were not made, even though the facility's policy required physician notification for significant changes in resident health status. One LPN admitted to being aware of high blood glucose readings but did not recall the notification parameters and had never contacted the physician. The regional clinical specialist confirmed that staff were expected to follow through with physician notification when ordered parameters were met.
Failure to Follow Edema Management Orders
Penalty
Summary
Facility staff failed to follow physician orders for edema management for a resident with chronic edema. The resident had an order to apply edema wear to her lower extremities in the morning and remove it at night. Observations showed the resident was not wearing the prescribed compression stockings during the day, despite staff documentation indicating the task had been completed. The resident reported needing assistance to put on the stockings, which were wet from being washed and left hanging in the bathroom. Staff continued to document that the edema wear was applied and removed as ordered, even though the resident was not wearing them. The resident had a history of hypertension, diabetes mellitus, arthritis, obesity, developmental disorder, and edema, and was taking a diuretic. She was cognitively intact and independent with daily activities but required help with the compression stockings. The facility did not have a specific policy on edema management, but staff were expected to follow physician orders. The failure to ensure the resident wore the prescribed edema wear as ordered constituted a deficiency in providing care according to the resident's needs and physician instructions.
Failure to Notify Family and Physician After Medication Error
Penalty
Summary
The facility failed to notify the family and physician after a medication error involving a resident who was given 40 milligrams (mg) of pantoprazole instead of the prescribed 20 mg daily dose over a period from 2/16/24 to 3/12/24. The resident, who had a moderate cognitive deficit and was dependent on staff for various activities of daily living, was admitted with diagnoses including osteomyelitis of vertebra, insomnia, muscle weakness, and low back pain. The error was discovered on 3/13/24, but there was no incident report or documentation of the error, and the family and physician were not informed. Three Certified Medication Aides (CMAs) were disciplined for administering the wrong dose on multiple occasions, but the facility lacked a policy on notifying family and physicians of such errors. The Director of Nursing (DON) acknowledged the error but did not have any incident reports or documentation related to it. The DON also admitted that the family and doctor had not been contacted regarding the error. A Registered Nurse (RN) who discovered the error reported it to the DON and the pharmacy but did not fill out an incident report or notify the family and physician, assuming the DON would handle it. The facility's Medication Administration Policy did not include directions for ensuring the correct dose was administered, and there was no policy on notification to family and physicians.
Failure to Update Care Plan for Resident with Respiratory Issues
Penalty
Summary
The facility failed to ensure the care plan for a resident was updated in a timely manner. The resident, who had chronic respiratory failure, COPD, and chronic pain, had a change in her BiPAP machine order from 2 liters of oxygen to 6 liters on 3/8/24. However, the care plan was not updated to reflect this change. This oversight led to multiple incidents where the resident's oxygen levels dropped significantly, causing her to experience severe respiratory distress. On one occasion, an agency nurse forgot to put the BiPAP on overnight, resulting in the resident's oxygen level dropping into the 70s by morning. Additionally, there were instances where the BiPAP oxygen level was set incorrectly, further exacerbating the resident's condition. Staff interviews and observations revealed that the resident's oxygen levels were often not maintained as per the updated order. The DON was unaware that the care plan had not been updated and admitted that there was no policy on following physician's orders or care plan updates. This lack of timely care plan updates and adherence to physician's orders contributed to the resident's repeated episodes of respiratory distress.
Failure to Follow Physician's Orders for Medication and BiPAP Settings
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to medication and treatment errors. Resident #25, who had a moderate cognitive deficit and multiple health issues, was prescribed pantoprazole 20 mg daily. However, due to a pharmacy error, 40 mg tablets were sent, and staff administered the incorrect dose from 2/16/24 through 3/12/24. Despite the error being discovered by a Registered Nurse, no incident report was filed, and the family and doctor were not informed. The facility's policy lacked direction for staff to double-check medication doses, contributing to the error going uncorrected for nearly a month. Resident #1, who had intact cognitive ability and chronic respiratory issues, had specific orders for her BiPAP machine to be set at 17V12 cm H2O pressure with 6 liters of oxygen per minute. However, staff failed to consistently follow these orders, resulting in the resident experiencing severe shortness of breath and low oxygen levels on multiple occasions. An agency nurse once forgot to put the BiPAP on overnight, causing the resident's oxygen level to drop significantly. Additionally, staff were observed setting the oxygen level incorrectly, either too low or too high, further exacerbating the resident's condition. The Director of Nursing (DON) acknowledged the errors but admitted that no incident reports or risk assessments were completed, and the family and doctor were not notified. The facility also lacked a policy on following physician's orders, which contributed to the repeated failures in administering the correct treatments to the residents. These deficiencies highlight significant lapses in the facility's medication administration and respiratory care protocols.
Failure to Timely Assess and Intervene for Resident's Injury
Penalty
Summary
The facility failed to assess and intervene in a timely manner for a resident who fell out of his wheelchair when it rolled off a van lift. The resident, who had a BIMS score of 15 indicating intact cognitive ability, sustained an injury to his right foot. Despite the resident's complaints of increased pain and decreased movement, the staff did not contact the doctor promptly. The resident's pain was documented multiple times, and the use of PRN Tylenol increased significantly after the fall, yet no immediate action was taken to address the worsening condition until much later. The resident's medical history included atrial fibrillation, morbid severe obesity, arthropathy, edema, weakness, venous thrombosis, and embolism. Initially, the resident was mostly independent with mobility but required a mechanical full-body lift for transfers after the fall. The incident report and subsequent nursing progress notes indicated that the resident experienced ongoing pain in his right foot and toes, which was not adequately addressed by the staff. The staff failed to communicate effectively with the physician about the resident's condition, relying on fax communication without follow-up. The Director of Nursing (DON) acknowledged that the facility did not have specific policies on change in condition and when to call the doctor, relying instead on standards of care and regulations. The lack of timely intervention and proper communication with the physician led to a delay in diagnosing the resident's fractures, which were only identified after a CT scan was ordered much later. This deficiency highlights the need for better assessment and communication protocols to ensure timely medical intervention for residents experiencing changes in their condition.
Failure to Provide Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide post-dialysis assessments for a resident who required such services. Resident #12, who had a BIMS score of 15 indicating intact cognitive ability, required dialysis treatments and had diagnoses including chronic kidney disease, stage 5, acidosis, obsessive-compulsive disorder, and malnutrition. The care plan for Resident #12 directed staff to monitor the fistula in her right arm daily and observe for signs of dehydration and fluid volume imbalance. However, the resident's chart lacked post-dialysis vital signs and assessments on multiple dates, specifically 4/12/24, 4/20/24, 4/29/24, 5/6/24, and 5/13/24. Interviews with staff revealed that the post-dialysis assessments were not consistently completed. Staff B, an RN, acknowledged that several post-dialysis assessments had not been edited, and Staff D, an LPN, indicated that the responsibility for completing these assessments was shared between the morning and afternoon nurses. The Director of Nursing stated that staff were supposed to complete an assessment with vital signs immediately upon the resident's return from dialysis. The facility's policy on post-dialysis assessment and documentation required obtaining vital signs, assessing the resident's physical condition, and checking the vascular access site, but these steps were not consistently followed for Resident #12.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pomeroy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Manson | 7.5 mi | ★★★★★ | 0 | 0 |
| Fonda Specialty Care | 8.7 mi | ★★★★★ | 4 | 0 |
| Sunny Knoll Care Centre | 10.5 mi | — | 0 | 0 |
| Park View Rehabilitation Center | 17.2 mi | ★★★★★ | 12 | 0 |
| Accura Healthcare Of Lake City, Llc | 19.6 mi | ★★★★★ | 8 | 0 |
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