Inspection·July 17, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Residents Affected - Some Based on observation, record review, review of a facility Self-Reported Incident (SRI) and investigation including witness statements, review of the facility Abuse policy and staff and resident interviews, the facility failed to ensure Resident #27 was free from staff to resident physical and verbal abuse. This resulted in Immediate Jeopardy and actual psychosocial and physical harm on 07/05/23 at approximately 11:00 A.M. when State Tested Nursing Assistant (STNA) #50 and STNA #60 witnessed Licensed Practical Nurse (LPN) #30 scream at Resident #27, grab the resident by the arm, and forcibly moving the resident from her wheelchair to a shower chair in the shower room. Resident #27 was observed by both STNAs to be sobbing uncontrollably and hyperventilating during the incident. STNAs #50 and #60 did not intervene appropriately or immediately report the abuse incident to the Administrator. LPN #30 continued to work on the floor for an additional two hours and 15 minutes following the incident before being relieved of her duties. This affected one resident (#27) of three residents reviewed for abuse and placed an additional 19 residents (#33, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #71) at risk for potential harm when LPN #27 had unrestricted access and continued working following the abusive incidents. The facility census was 70. On 07/13/23 at 11:55 P.M., the Administrator was notified the Immediate Jeopardy began on 07/05/23 at approximately 11:00 A.M., when Resident #27 was witnessed being physically and verbally abused by LPN #30. On 07/05/23 at 11:00 A.M., STNA #50 and STNA #60 observed LPN #30, enter the facility shower room after being asked for assistance with Resident #27. LPN #30 entered the shower room and pointed her finger at the resident and stated, You will be getting a shower today or you will be going to psych. The nurse then stated, You are either going to psych or getting the needle, I've done it before, and I'll do it again. At this point, Resident #27 began crying and physically swung her arm at LPN #30. The nurse then forcibly grabbed the resident by the arm and pulled it up to place her other arm under the resident. The nurse then transferred the resident to a nearby shower chair with enough force to knock several items off a nearby shelf which scattered all over the floor. At this point, Resident #27 was observed by both STNAs to be sobbing uncontrollably and hyperventilating. LPN #30 then left the shower room to return to her duties as the floor nurse. STNA #50 and #60 did not report the physical and verbal abuse immediately. Both STNAs then completed the shower for Resident #27 and finished at approximately 11:55 A.M., at which time the resident was noted to be calm. Both STNAs then reported the incident to Registered Nurse (RN) #90 after assisting the resident to her bed. The facility did not immediately suspend LPN #27 and she continued to work over two hours and 15 minutes providing care to the residents and passing medications following the incident, until 1:15 P.M. which placed the other residents at risk for potential further abuse. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365450 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Pomeroy 36759 Rocksprings Road Pomeroy, OH 45769 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)