Pocahontas Center

In the surveyor’s words

From the most serious findings on record at Pocahontas Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 1, 2024

  Based on record review and staff interview the facility failed to ensure residents were free from abuse from other residents. Beginning on 04/19/23 Resident #20 began displaying physical, verbal and sexually abusive behaviors towards residents and staff. A review of the record found at least 20 noted incidents of such behavior. The abusive behavior was not consistently reported as required, the physician and responsible party was not consistently notified, the victims were not consistently identified, and interventions were not consistently put into place to prevent the abuse from reoccurring. Resident #20 still currently resides at the facility and has had documented episodes of said behaviors as recent as 07/05/24. […]

• Immediate jeopardy, isolatedF807Dec 17, 2025

  Based on record review, observation. and staff interview the facility failed to ensure Resident #8 was served liquid in a form which met his individualized needs. Resident # 8 was ordered and care planned to receive nectar thickened liquids however during the noon time meal on 12/16/25 the resident was served regular consistency milk and regular consistency coffee. The resident did drink the thin liquids and experienced coughing. This was a random opportunity for discovery and was true for Resident #8. The State Agency (SA) determined the facility's failure to serve Resident #8 with nectar thickened liquids place him at immediate risk for serious harm and/or death. […]

• Immediate jeopardy, isolatedF689Nov 5, 2025

  Based on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #46 was transferred to from her geri chair to her bed in a manner which was not safe for her. Resident #46 was found to be totally dependent on staff for transfers. The staff were to utilize a total mechanical lift to transfer the resident from the chair to the bed and from the bed to the chair. Two (2) nurse aides were observed taking Resident #46 into her room. The surveyor stood outside the resident door and kept the room under constant sight. When the nurse aides emerged from the room the resident was in the bed. […]

• No harm, potential for more than minimal, widespreadF725Nov 5, 2025

  Based on record review and staff interview, the facility failed to ensure sufficient nursing staff across all shifts. This was true for 18 of 45 days reviewed under the care area of staffing. Facility Census: 59.Findings Include: a) Staffing On 09/30/2025 at 2:00 PM, 45 daily nurse staff postings were reviewed. The minimum staffing requirement is 2.25. The review found the following days did not meet the minimum of nursing hours per patient days (NHPPD): 09/21/24 2.1104/19/24 2.0904/20/25 2.2005/17/25 2.2005/24/25 1.4805/25/25 2.1505/31/25 2.1806/01/25 1.8806/07/25 1.6406/21/25 1.8206/22/25 2.0106/23/25 1.9506/25/25 2.2106/27/25 2.0806/28/25 1.9306/29/25 2.0706/30/25 2.2007/05/25 2.05 On 09/30/25 at 4:40 PM, the Administrator and the Regulatory Compliance Advisor #73 confirmed the minimum… […]

• No harm, potential for more than minimal, widespreadF732Nov 5, 2025

  Based on record review and staff interview, the facility failed to provide an accurate and complete daily staff postings. This was true for four (4) of 45 daily staff postings reviewed. Facility Census: 59.Findings Include: a) Daily Staff Postings On 09/30/2025 at 2:00 PM, a review of daily staff postings was completed. The following days did not include the census: --05/10/25 day shift, evening shift, night shift--05/22/25 day shift, evening shift, night shift --06/06/25 day shift, evening shift, night shift--06/24/25 night shift On 09/30/25 at 4:40 PM, the Administrator and Regulatory Compliance Advisor #73 confirmed the daily staff postings did not list the census number.