The incident at Accura Healthcare of Pomeroy illustrates a broader pattern of untrained temporary staff working independently with the facility's 36 residents, according to a federal inspection completed August 13.
Staff L, a certified nursing aide with a staffing agency, was assisting residents with transfers on her second day at the facility. She hadn't worked there for six months. When asked about orientation, she said she didn't get one and didn't remember any education checklists being offered before she worked independently with residents.
The facility's own checklist showed orientation should include facility tours, resident care procedures, mechanical lift training, and emergency protocols. But multiple temporary workers told inspectors they never received this training.
Staff E, another temporary aide, worked an overnight shift the previous Sunday as the only aide on the floor. She attempted to transfer Resident #2 without using the required mechanical lift because he told her he could stand. When she discovered he couldn't stand, she lowered him back onto the bed.
Staff E said she received no orientation or education before working independently with residents.
Staff M, who worked overnight shifts, also reported getting no orientation or education. She said she knew how to transfer residents and provide care because she had been a certified nursing aide for a long time.
But experience elsewhere didn't translate to knowledge of this facility's specific procedures and residents' individual needs.
Staff D, a registered nurse who usually worked weekends, said when she first started she was expected to come in an hour early and another nurse showed her around the building. She didn't remember getting a complete orientation or a signed checklist.
The facility's administrator and assistant director of nursing told inspectors on August 12 they had orientation checklists for agency staff. With the director of nursing absent, they said they would look for documentation showing temporary staff had been oriented.
They specifically mentioned three workers: Staff C, Staff E, and Staff D.
The next day, administrators said many orientation checklists were on the director of nursing's desk, except for the three staff members that had been requested.
The missing documentation highlighted the gap between policy and practice.
Resident #5 sat in her wheelchair in the dayroom with bruising on her left arm from a recent hospitalization. She was on dialysis and said she was feeling much better. But she expressed concern about good staff leaving and temporary aides not knowing what they were doing.
That morning provided a stark example. She had to explain to the certified nursing aide how to help her with her catheter and toileting needs.
The facility's own Agency Staff Checklist outlined comprehensive orientation requirements. Temporary workers should receive facility tours, learn shift routines and general duties, and get training on resident care procedures including mechanical lifts.
The checklist covered documentation requirements, narcotic counts, medication deliveries, and guidelines for reporting changes in resident condition. It included communication protocols for door alarms, telephones, and walkie-talkies.
Training was supposed to cover the facility's abuse policy, including what to report and when. Staff should learn procedures for resident incident reports covering falls, skin protocol, medication errors, and deaths.
Emergency procedures formed another critical component: physician and hospital contacts, fire and weather protocols, elopement response, and emergency care procedures.
The checklist required staff acknowledgment that they had received training on all guidelines and information needed to perform their job duties. It noted the orientation wasn't intended to cover every situation that might arise during assignment, but provided general guidelines for safe resident care.
None of the temporary staff interviewed had signed such acknowledgments or received the outlined training.
The violation occurred at a time when nursing homes nationwide struggle with staffing shortages, often relying heavily on temporary workers to maintain basic operations. But federal regulations require facilities to ensure all staff have necessary skills and training regardless of their employment status.
Staff E's attempt to transfer a resident without proper equipment illustrated the potential consequences. Mechanical lifts exist to protect both residents and workers during transfers. Bypassing safety equipment based on a resident's self-assessment could result in falls, injuries, or other harm.
The overnight shift presented particular risks. Staff E worked alone as the only aide on the floor, responsible for multiple residents' care needs throughout the night. Without proper orientation to the facility's procedures, emergency protocols, and individual resident requirements, she was unprepared for situations that required immediate, informed responses.
Resident #5's experience demonstrated how inadequate training affects daily care quality. Catheter care requires specific knowledge and techniques to prevent infections and other complications. When residents must instruct their caregivers, it signals a fundamental breakdown in professional care standards.
The administrator's acknowledgment that orientation checklists were missing for the requested staff members confirmed the inspection findings. Documentation gaps suggested either that training never occurred or that the facility failed to maintain required records of staff preparation.
Federal regulations mandate that nursing homes ensure staff competency before allowing independent resident care. The requirement applies equally to permanent employees and temporary workers, recognizing that all staff must understand facility-specific procedures, resident needs, and emergency protocols.
The facility's reliance on temporary staff without proper training created ongoing risks for its 36 residents. Each untrained worker represented potential gaps in care quality, safety protocols, and emergency response capabilities.
Resident #5's observation about good staff leaving highlighted another dimension of the problem. High turnover combined with inadequate temporary staff training created a cycle where residents received inconsistent care from workers unfamiliar with their specific needs and the facility's procedures.
The inspection found that temporary nurses and certified nursing aides were expected to perform job duties without proper training, creating minimal harm or potential for actual harm to residents. The violation affected few residents directly but represented systemic problems that could impact the entire facility population.
Staff D's experience as a registered nurse illustrated that even licensed professionals needed facility-specific orientation. Her informal building tour fell far short of the comprehensive training outlined in the facility's own checklist, leaving gaps in her knowledge of procedures, protocols, and resident care requirements.
The missing orientation checklists for three specific staff members suggested broader documentation problems. If the facility couldn't locate training records for workers specifically requested during the inspection, it raised questions about training documentation for other temporary staff members.
Resident #5 continues to require dialysis and catheter care, depending on staff who understand her specific medical needs and can provide appropriate assistance without requiring her instruction.
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
- View all inspection reports for Accura Healthcare of Pomeroy, LLC
- Browse all IA nursing home inspections
