Arbors at Pomeroy

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident's comprehensive care plans addressed the resident's known problem with constipation related to a malignant neoplasm of the colon, use of opioid pain medication, and receiving stool softeners/ laxatives on a scheduled basis for constipation. This affected one (Resident #55) of 23 residents reviewed for care plans.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure a resident received the appropriate medications, in accordance with his physician's orders, to properly manage/ treat his known chronic diarrhea. This affected one (Resident #9) of one residents reviewed for constipation/ diarrhea.

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure fall prevention interventions were in place per the plan of care for Resident #8 and #33. The facility also failed to ensure additional safety interventions were in place for seizure precautions and hot beverages for Resident #8. This affected two (#8 and #33) of three residents reviewed for accidents. The facility census was 66.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were not administered outside of physician ordered parameters. This affected one Resident (#4) of five sampled for unnecessary medication use. The facility census was 66.

Inspectors wroteBased on record review, observation, review of the facility's spreadsheet for therapeutic menus, interview, and policy review, the facility failed to ensure a resident received all food items included on the menu for their ordered therapeutic diet. This affected one (Resident #71) of one residents, who the facility identified as being on a renal diet.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure residents had assistive devices in place for meals. This affected one (#33) of one resident reviewed for assistive devices. The facility census was 66.

Inspectors wroteBased on interview, record review, policy review, and review of narcotic log the facility failed to ensure narcotic medication and insulin were administered by a licensed qualified staff member. This affected two residents (#18, #64) of 32 residents who had narcotic and/or insulin orders. The census was 71.

Inspectors wroteBased on observation, medical record review, review of Emergency Medical Service (EMS) reports, review of hospital records, review of National Weather Service website, review of a facility investigation, and resident and staff interviews, the facility failed to ensure adequate and proper interventions were provided to prevent resident heat stroke during an outside activity. The facility also failed to ensure outdoor activities were planned and provided to meet the safety and total care needs of residents. This resulted in Immediate Jeopardy and actual harm and/or adverse health outcomes on 06/21/25 when facility staff took 13 residents to the zoo with the outside temperature reaching 88 degrees with a heat index of 90. The residents were at the zoo from approximately 12:00 P.M. to 6:00 P.M. Residents complained of not feeling well and being hot at the zoo. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to develop and implement a baseline plan of care related to Resident #116's orthotic splint. This affected one resident (#116) of 19 sampled residents. Findings Include: [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to review and revise two residents (#5, #46) in the area of activities of daily living (ADL) and palliative care. This affected two residents (#5, #46) of 19 sampled residents. Findings Include: 1. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to provide ensure one resident (#24) who was dependent on staff assistance with nail care as physician ordered. This affected one resident (#24) of three residents reviewed for activities of daily living (ADL). Findings Include: [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#46) received routine palliative care visits. Additionally, the facility failed to monitor one resident's (#116) orthotic splint causing increased edema. This affected two residents (#46, #116) of 19 sampled residents. Findings Include: 1. Review of the medical record for Resident #46 revealed an initial admission date of 03/08/23 with the latest readmission of 04/02/24 with the diagnoses including but not limited to acute and chronic respiratory failure, severe morbid obesity, chronic obstructive pulmonary disease (COPD), hypothyroidism, depression, diabetes mellitus, pain in foot, sleep disorder, liver disease, fatty liver and gout. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure residents (#24, #50) were provided routine podiatry services. This affected two residents (#24, #50) of three residents review for activities of daily living (ADL). Findings Include: 1. [...]

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for residents with a history of falls and another resident known to have non-pressure skin injuries had a footboard padded as per their plan of care. This affected three residents (#29, #37, and #50) of seven residents reviewed for accidents.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to address a pharmacy recommendation timely for one resident (#24). Additionally, the physician failed to provide a rationale for the decline of a pharmacy recommended gradual dose reduction (GDR) for Resident #5. This affected two residents (#5, #24) of five residents reviewed for unnecessary medications. Findings Include: 1. [...]

Inspectors wroteBased on medical record review and interview the facility failed to obtain physician ordered laboratory testing for one resident (#45) of five sampled for unnecessary medications. The facility census was 66.

Inspectors wroteBased on record review, review transfer notices, staff interview, and policy review, the facility failed to ensure the local Ombudsman was notified of resident transfers as required. This affected two residents (#57 and #65) of two residents reviewed for hospitalizations.

Inspectors wroteBased on observation, record review, review of the facility's fall investigation, staff interview, and policy review, the facility failed to ensure Resident #55 was provided the assistance needed to prevent an avoidable fall from occurring that resulted in major injury to the resident and failed to ensure Resident #44's room was free of a safety hazard (an electrical heated curling iron). This affected two residents (#55 and #44) of three residents reviewed for accidents. The facility census was 65. Actual harm occurred on 09/26/23 when Resident #55, who was severely cognitively impaired was observed ambulating in the hall, without the use of her walker, and was only educated by a staff member that she needed her assistive device when ambulating. [...]

Inspectors wroteBased on medical record review, policy review, and staff interview, the facility failed to ensure the accuracy of a resident's advance directives. This affected one of 24 sampled residents (#7). The facility census was 65.

Inspectors wroteBased on record review, observation and interview, facility failed to maintain a homelike environment in resident rooms. This affected two residents (#18 and #55) of four residents reviewed for homelike environment. The census was 65.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the area of gradual dose reduction attempts being completed when on an antipsychotic medication and the use of personal alarms and wander guards. This affected two residents (#18 and #36) of 23 residents reviewed for assessments.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents had a new resident review completed after a newly diagnosed mental illness was added to their diagnoses. This affected two residents (#12 and #43) of two residents reviewed for Preadmission Screening and Resident Review (PASARR) assessments.

Inspectors wroteBased on medical record review, staff interview, policy review, the facility failed to ensure a residents care plan properly reflected a resident's code status. This affected one resident (#67) of the 23 residents reviewed for accurate care planning. The facility census was 65.

Inspectors wroteBased on medical record review and staff interview, the facility failed to obtain ordered weekly weights for nutritional support monitoring. This affected one resident (#15) of the two residents reviewed for nutrition. The facility census was 65.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure a resident receiving supplemental oxygen had a physician's order to administer oxygen and a physician's order to specify the flow rate in which it was to be received. This affected one resident (#16) of two residents reviewed for respiratory care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure as needed antipsychotic medication had an appropriate diagnosis for use and was not administered to residents prior to attempting nonpharmacologic interventions. This affected one resident (#36) of six residents reviewed for unnecessary medications. The facility census was 65.

Inspectors wroteBased on record review and interview, facility failed to ensure a resident received an antibiotic for an appropriate diagnosis. This affected one resident (#223) of six residents reviewed for antibiotic stewardship. The facility census was 65.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #4, a male resident who displayed inappropriate sexual behaviors prior to admission to the facility was not placed in a room with a bathroom that adjoined to another room where a female resident, Resident #74 resided. This affected two residents (#4 and #74) of the three residents reviewed for appropriate care planning. The facility census was 63.

Inspectors wroteBased on medical record review, self-reported incident review, staff interview, and facilities policy review, the facility failed to report an allegation of sexual abuse in a timely manner and to the appropriate State agency. This affected one resident (#74) of three residents reviewed for reporting allegations of abuse. The facility census was 63.

Inspectors wroteBased on medical record review and staff interview, this facility failed to develop a comprehensive person centered care plan to reflect behaviors including inappropriate sexual behaviors. This affected one resident (#4) of three residents reviewed for care planning. The facility census was 63.