Accura Healthcare of Pomeroy, LLC

In the surveyor’s words

From the most serious findings on record at Accura Healthcare of Pomeroy, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 17, 2021

  Based on observation, record review, resident and staff interviews the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 6 residents (Resident #1). Resident #1, a resident with cognitive impairment, exited the facility without staff knowledge. Staff did not know the resident was gone until they received a phone call alerting them the resident was at a local bar and grill establishment. The facility reported a census of twenty-three (23) residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. The MDS assessed the resident with a BIMS (brief interview for mental status) score of 3 (severe cognitive impairment). […]

• No harm, potential for more than minimal, widespreadF851May 1, 2025

  Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 1, 2025 review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 26 residents. Findings include: The PBJ Staffing Data Report with a run date of 4/23/25, for the 1st quarter of the fiscal year 2025; (October 1 - December 31), triggered for a failure to have licensed nursing coverage 24 Hours/Day. Infraction dates included: 10/19, 10/20, 11/28, 12/2, 12/3, 12/4, 12/5, 12/6, 12/8, 12/9, 12/10, 12/11, 12/13, 12/16, 12/17, 12/18, 12/19, 12/20, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/30 and 12/31. […]

• No harm, potential for more than minimal, patternF880May 14, 2026

  Based on observations, staff interviews, Electronic Health Record (EHR) review, and policy review, the facility failed to complete appropriate hand hygiene for 3 of 4 residents observed (Resident #16, #19 and #20). The facility further failed to apply a gown when completing catheter care on a resident (Resident #2) with Enhanced Barrier Precautions (EBP). The facility reported a census of 24 residents. Findings include:1.The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 that indicated no cognitive impairment. The MDS also documented Resident #2 utilized an indwelling catheter. […]

• No harm, potential for more than minimal, patternF868May 12, 2022

  The facility failed to assure the quality assessment and assurance (QAA) committee met at least quarterly. The facility reported a census of 20 residents. Findings include: A list of quality assurance and performance improvement (QAPI) meetings since the facility's last re-certification survey, showed a missing meeting the fall of 2021, and no meeting the winter of 2022. A review of QAPI/QAA meeting sign in sheets showed a meeting held 7/21/21 and then not again until 4/21/22. On 5/12/22 at 11:34 a.m. the Administrator stated they were sure they had a meeting in October, but could not find a sign-in sheet to show that. They did not have a meeting in January because they had an outbreak of novel Coronavirus 2019 (COVID-19). […]

• No harm, potential for more than minimal, patternF812Jan 7, 2021

  Based on observation and staff interview, the facility failed to maintain a clean stove hood and failed to serve food under sanitary conditions. The facility reported a census of 22 residents. Findings include: 1. Initial tour of the kitchen on 1/4/21 at 10:15 a.m., revealed the stove hood filters contained a gray material that appeared to be dust directly above 6 stove burners. Staff A (cook) verified the material looked like dust and the filters needed washed. Staff A stated a commercial company cleaned the hood once a year and came in March of 2020. Staff A did not know how often the facility cleaned the filters. On 1/4/21 at 11:00 a.m., the Maintenance Supervisor verified the stove hood required cleaning now, scheduled for monthly cleaning, and he last cleaned it in November of 2020. […]