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 (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 2 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 08/12/2025 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)