Accura Healthcare Pomeroy: Resident Abuse Allegations - IA

The resident, identified only as Resident #2 in federal inspection documents, told investigators on August 12 that he would "roll out of bed on purpose and put himself on the floor so the alarm would go off and it would get their attention." He pointed to a mat placed next to his bed and said "I do it on purpose."

When asked about rough treatment from staff, the resident said "there was one who grabbed his arm, mostly the right arm and said it's almost healed now." He explained the staff member was trying to prevent him from getting into the bathroom.

The resident also said he sometimes bumped his arms on side rails when staff rolled him over in bed.

Federal inspectors found that Accura Healthcare of Pomeroy failed to properly investigate and document incidents involving the resident after abuse allegations surfaced on July 5. Multiple staff members reported that combative incidents weren't being documented, despite facility policies requiring incident reports for new injuries.

Staff G, a certified nursing assistant, told inspectors on August 12 that since the July 5 abuse allegations, "they started taking pictures of all new bruises." She said there were many times the resident would get combative during care, and when staff reported it, "they were told that he just didn't like them and to step away from him."

The nursing assistant described one incident where staff were transferring the resident with a mechanical lift. He raised his fist and hit the lift's arm, which bruised his hand.

Staff C, a certified medication aide, said many combative incidents involving Resident #2 "wasn't documented." She displayed a bruise on her leg where the resident "slammed his wheel chair into her."

Another nursing assistant, Staff I, said there were many past incidents where Resident #2 was combative and hit her. She reported the incidents to nursing staff and the administrator but "was told to just get away from him." She said she didn't see any new interventions or documentation completed.

Staff B, another certified nursing assistant, said Resident #2 often had bruising on his arms and would get agitated when staff tried to clean him. The assistant said he would report incidents to nurses whenever they happened.

The facility's Director of Nursing acknowledged that Resident #2 often had bruises on his arms because he would bump them on walls and bed side rails. She admitted they "hadn't been keeping track of the bruising before the incident on 7/5/25."

The administrator told inspectors that Resident #2 often got caught up on hall arm rests and in doorways, which caused bruising. She said if there were incidents between residents and staff such as hitting or running his wheelchair into them, staff should step back and there should be a behavior note in nursing documentation. The facility would do an incident report "if/when the resident sustained new injury."

However, multiple staff members indicated this protocol wasn't being followed consistently before the July abuse allegations.

The inspection revealed a pattern where staff concerns about combative behavior weren't being properly addressed through documentation or intervention strategies. Instead, workers were simply told to avoid the resident when he became agitated during care.

According to facility policy dated May 6, 2023, titled "Skin Management Protocol," staff are required to notify the Director of Nursing and wound nurse of new skin alterations and complete incident reports and skin sheets. The inspection found this policy wasn't being consistently implemented.

The federal citation indicates the facility failed to ensure residents were free from abuse and that all alleged violations were thoroughly investigated. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.

Staff accounts suggest a disconnect between management directives and actual documentation practices. While administrators acknowledged the need for proper reporting, frontline workers described being discouraged from filing incident reports for combative behavior.

The resident's deliberate falls represented an extreme measure to get attention from staff who he felt weren't responding to his needs appropriately. His statement that he would roll out of bed "on purpose" to trigger alarms indicates he felt this was his only reliable way to get staff response.

The inspection documents don't indicate whether the staff member who allegedly grabbed the resident's arm faced any disciplinary action or whether additional training was provided to prevent similar incidents.

The case highlights challenges nursing homes face in balancing resident safety with appropriate response to combative behavior. Staff described feeling caught between providing necessary care to an agitated resident and following directives to step away when he became combative.

The facility's acknowledgment that they only began systematically tracking bruises after the July 5 abuse allegations suggests previous injuries may not have been properly monitored or investigated.

Federal inspectors completed their review on August 13, 2025, following up on complaints that triggered the investigation. The inspection focused specifically on the facility's handling of abuse allegations and documentation practices for incidents involving combative residents.

The resident's bruising was attributed to various causes including bumping into walls, door frames, and bed rails, as well as incidents during care provision. However, the lack of consistent documentation made it difficult to determine patterns or implement appropriate interventions.

Staff injuries from the resident's combative behavior, including the wheelchair collision that bruised one worker's leg, weren't being consistently reported through proper channels according to worker accounts.

The inspection findings indicate systemic issues with incident reporting and investigation procedures that extended beyond the single abuse allegation that triggered the federal review.

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

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