Health inspection·August 12, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: 1.Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, cerebrovascular disease, asthma, dysphagia, peripheral vascular disease, lymphedema, cognitive impairment, restless leg syndrome, major depressive disorder, hypertension, and hyperlipidemia. Review of Resident #18's quarterly Minimum Data Set (MDS) completed 07/11/25 revealed a brief interview for mental status (BIMS) score of 14. Record review of Resident #18's orders revealed an order placed on 04/28/25 for hydrocodone-acetaminophen oral tablet 5-325 milligram (mg), give one tablet by mouth every 12 hours as needed for severe pain. Review of Resident #18's electronic medication administration record progress notes revealed a note authored by Certified Medication Aide/Tech #3 on 08/02/25 at 8:51 P.M. stating as needed hydrocode acetaminophen oral tablet 5-325mg was administered by Certified Medication Aide/Tech #3. Review of Resident #18's electronic medication administration record progress notes revealed a note authored by Certified Medication Aide/Tech #3 on 08/03/25 at 9:10 P.M. stating as needed hydrocode acetaminophen oral tablet 5-325mg was administered by Certified Medication Aide/Tech #3.Review of Resident #18's Medication Administration Record (MAR) revealed Certified Medication Aide/Tech #3 administered hydrocode acetaminophen oral tablet 5-325mg on 08/02/25 and 08/03/25. Review of Resident #18's controlled drug receipt/record/disposition form revealed Certified Medication Aide/Tech #3 signed off they had administered hydrocode acetaminophen oral tablet 5-325mg on 08/02/25 and 08/03/25. Review of MedScape medication formulary revealed hydrocode acetaminophen is a class level II narcotic medication with a warning of serious, life-threatening, or fatal respiratory depression. 2. Record review revealed Resident #64 was admitted to the facility 04/02/18 with diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, spastic hemiplegia affecting left side, cerebral infarction, myocardial infarction, dysphagia, dementia, schizoaffective disorder, hypertension, and major depressive disorder. Review of Resident #64's orders revealed an order for NovoLog (insulin aspart) Flex pen subcutaneous pen injector 100 unit/ milliliter (ml) inject per sliding scale ordered on 01/23/24. Review of Resident #64's August 2025 MAR revealed on 08/02/25 Certified Medication Aide/Tech #3 administered four units of insulin aspart to Resident #64. Review of Resident #64's August 2025 MAR revealed on 08/03/25 Certified Medication Aide/Tech #3 administered eight units of insulin aspart to Resident #64. On 08/12/25 at 1:31 PM interview with Administrator #74 confirmed Certified Medication Aide/Tech #3 had not completed her training at her time of termination on 08/06/25 (termination due to attendance reasons), therefore would have been unqualified to administer narcotics and insulin to residents. On 08/12/25 at 1:31 PM interview with Registered Nurse (RN) #136 confirmed on 08/02/25 and 08/03/25 Certified Residents Affected - Few Page 1 of 2 365450 365450 08/12/2025 Arbors at Pomeroy 36759 Rocksprings Road Pomeroy, OH 45769

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medication Aide/Tech #3 administered insulin to Resident #64 and narcotics to Resident #18 while un-qualified to do so. Review of Certified Medication Aide/Tech #3 personnel file revealed no documentation or evidence they were qualified or trained to administer insulin and/or narcotics to residents. Review of facility policy titled Medication Administration (implemented 10/30/20 and revised 01/17/23) revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number 2583769. 365450 Page 2 of 2