Accura Healthcare of Pomeroy: Medication Left on Food Tray - IA
The incident at Accura Healthcare of Pomeroy happened on a Sunday night. Agency staff, filling in for the facility's regular nursing employees, had set the medications down on the tray and left them there without telling the resident they were there. The resident had no idea the medications were sitting in front of them.
It was kitchen staff who caught it. They picked up the tray during a routine clearing, found the cup of pills, and brought it to Staff J, a nurse, who then took the medications to the resident to administer them.
By that point, the medication pass had already gone wrong in almost every way it could.
The administrator described the situation to inspectors on the morning of August 13, 2025. She said the facility does not have any residents assessed to self-administer medications without supervision. "We don't do that here," she said. She added that nurses are expected to know the five rights of medication administration and to double-check their work during every medication pass.
The five rights she referenced are a basic framework taught in nursing school: the right resident, the right drug, the right dose, the right route, the right time. Leaving a cup of medications on a food tray and walking away is a failure of the first right before any of the others can even apply. The nurse who set the medications down had no way of confirming the resident received them, no way of confirming the resident took them correctly, and no way of knowing whether the resident even understood what was in the cup.
The resident, identified in the inspection report only as Resident 3, was not assessed as capable of managing their own medications. That matters because residents who cannot self-administer medications independently are, by definition, dependent on staff to ensure the medications reach them safely. The kitchen worker who found the cup was not a medication aide. Handing a cup of pills to a passing nurse and hoping it gets sorted out is not a medication administration system.
CMS classified the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. The complaint inspection was completed August 13, 2025.
What the report leaves open is whether the medications were ever confirmed as taken correctly, whether the resident experienced any delay in receiving a time-sensitive drug, and whether the agency staff member who left the cup on the tray faced any consequence. The administrator's comments to inspectors focused on what nurses are supposed to know, not on what happened after the kitchen staff intervened or how the facility confirmed the resident was not harmed.
In a facility where no resident is assessed to self-administer medications unsupervised, a cup of pills sitting on a food tray is not a minor lapse in paperwork. It is a breakdown in the most fundamental transaction in a nursing home: a nurse, a resident, and the moment of administration, confirmed and witnessed. None of that happened on a Sunday night in Pomeroy.
The kitchen staff found the medications. The kitchen staff handed them off. And somewhere between the nurse who set the cup down and the resident who eventually received it, the chain of accountability had already broken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Pomeroy, LLC from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 22, 2026 · Our methodology
Accura Healthcare of Pomeroy, LLC in Pomeroy, IA was cited for violations during a health inspection on August 13, 2025.
The incident at Accura Healthcare of Pomeroy happened on a Sunday night.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.