Poet's Seat Healthcare Center

In the surveyor’s words

From the most serious findings on record at Poet's Seat Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF580May 28, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that the Provider was contacted regarding a significant change in condition relative to a medication and/or the need to alter treatment for one Resident (#13) out of a total sample of 16 residents. Specifically, for Resident #13, the facility failed to notify the Provider (Physician/Nurse Practitioner [NP]/ Physician Assistant [PA]) when the Resident's scheduled Oxycodone (short-acting opioid medication used to treat moderate to severe pain) was unavailable to be administered, resulting in increased pain and psychosocial upset for the Resident. […]

• Actual harm, isolatedF697May 28, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure that pain management was provided in accordance with the individual goals for care and preferences for one Resident (#13) out of a total sample of 16 residents. Specifically, for Resident #13, the facility failed to administer scheduled Oxycodone (short-acting opioid medication used to treat moderate to severe pain) medication as ordered by the Physician, and failed to provide any other pain relieving measures, resulting in an increase in physical pain and psychological upset for the Resident. […]

• Actual harm, isolatedF740Nov 2, 2022

  Based on observation, interview and record review, the facility failed to ensure its staff provide behavioral health care and services for one Resident (#26), out of 17 sampled residents. Specifically, the facility staff failed to follow up on behavioral health recommendations for the Resident who was experiencing symptoms of depression. Findings include: Resident #26 was admitted to the facility in September 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Assessment, dated 8/25/22, indicated a Behavioral Interview for Mental Status (BIMS) score of 13 out of 15, indicating he/she was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2024

  Based on observation, interview, and policy review, the facility failed to ensure that food served to the residents was prepared in accordance with professional standards for food service and safety. Specifically, the facility staff failed to ensure that the microwave, ovens, food mixer, and ice machine equipment in the facility's main kitchen was maintained in a clean and sanitary manner, to prevent contamination and the risk of foodborne illnesses. Findings include: Review of the facility's Kitchen Sanitation and Infection Control policy, undated, included but was not limited to: -The Dietary Manager (Food Service Director) is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department. […]

• No harm, potential for more than minimal, widespreadF882Jul 27, 2021

  Based on policy review and interview, the facility failed to designate an individual as an Infection Preventionist (IP). Findings include: Review of the facility's Covid-19 Policy and Procedure binder, indicated that the staff member who was designated as the IP no longer worked at the facility. During an interview on 7/23/21 at 11:16 A.M., the Administrator said that the Director of Nurses (DON) who used to work at the facility had remained the facility's IP. During a telephone interview on 7/23/21 at 12:40 P.M., the previous DON said she had left her job at the facility in December of 2020. […]