Poet's Seat Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one Resident (#32) out of a total sample of 14 residents, was free from physical restraints. Specifically, the facility failed to ensure Resident #32's wheelchair brakes were unlocked while seated in a wheelchair, in front of a counter, restricting his/her ability to move freely when the Resident had a history of attempting to stand up from a seated position.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adequately assess the urinary status for one Resident (#12) of three applicable residents, out a total sample of 16 residents, when the Resident was admitted to the facility with an indwelling urinary catheter. Specifically, the facility failed to: -Identify the Resident's indwelling urinary catheter specifications, including size of catheter, type of catheter and size of balloon. -Obtain instructions from the Physician timely to ensure proper care for the Resident's indwelling urinary catheter, putting the Resident at risk for delays in urinary catheter care and urinary catheter associated complications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented, for one Resident (#13) out of a total sample of 16 residents, resulting in an inaccurate depiction of both pain medication administered and the Resident's pain status, and having the potential to affect the Resident's treatment plan. Specifically, for Resident #13, the facility failed to: 1. Document the administration status of scheduled doses of Oxycodone (short-acting opioid medication used to treat moderate to severe pain) in the Resident's Medication Administration Records (MAR) on 8/7/24, 11/13/24, and 11/21/24. 2. Accurately document the Resident's pain level for one assessment of pain on 5/27/25.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to accurately assess the urinary status on one comprehensive Minimum Data Set (MDS) Assessment for one Resident (#12) of three applicable residents, out of a total sample of 16 residents. Specifically, the facility failed to accurately code the Resident's comprehensive MDS Assessment to indicate that the Resident had an indwelling urinary catheter when the Resident was admitted to the facility with a chronic indwelling urinary catheter, putting the Resident at risk of not receiving urinary catheter care as required.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1), who was severely cognitively impaired and had a history of disrobing in public and intrusive wandering, and (Resident #2) who was severely cognitively impaired and had a history of inappropriate touching, the Facility failed to ensure they developed and implemented a Comprehensive Plan of Care that identified goals, interventions and outcomes related to Resident #1 and Resident #2's behaviors.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1, who was known to intrusively wander and disrobed in public areas, and Resident #2 who was known to exhibit inappropriate behaviors to residents of the opposite sex), the Facility failed to ensure Resident #1 and Resident #2 were provided with an adequate level of staff supervision in effort to reduce the potential for a resident to resident altercation.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) and/or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) were issued for two Residents (#12 and #36) out of a total sample of three residents. Specifically, the facility failed to issue: 1. A NOMNC notice and a SNF ABN notice to Resident #12. 2. A SNF ABN notice to Resident #36. NOMNC notice is issued to a resident who is receiving benefits under Medicare Part A when all covered services end. A resident must be told in advance when changes will occur in their bills, and the facility must fully inform the resident of service-related changes and appeal rights. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide an environment that was free of accidents and hazards for two Residents (#10 and #46) out of a total sample of 15 residents. Specifically, the facility staff failed to: 1. For Resident #10, ensure a fall event was investigated and interventions were implemented to prevent further falls for a Resident who was identified as being at risk of falling. 2. For Resident #46, provide maintenance and testing of a wander guard device (a device worn by the Resident, usually in a bracelet form, which alarms when the Resident attempts to leave a secure area of the facility) for a Resident who was identified as being at risk for elopement.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that the breakfast meal was served at a palatable temperature on one Unit (South Unit) out of two units observed. Specifically, the facility staff failed to: -address Resident Council concerns pertaining to meal temperatures. -ensure that breakfast meals on the South Unit were served to the residents at a palatable and appetizing temperature as indicated by test tray tasting completed for breakfast on South Unit.

Inspectors wroteBased on interview, policy, and record review, the facility failed to implement smoking policies as required for one Resident (#49) out of one applicable Resident, out of a total sample of 15 residents, and also failed to ensure that the Resident smoking area was maintained in a safe, clean and sanitary manner. Specifically, the facility staff failed to: 1. For Resident #49, ensure that smoking assessments and Resident Agreement for safe smoking habits were completed quarterly as required. 2. Establish a cleaning schedule to empty the cigarette disposal receptacles timely and replace a missing cigarette disposal receptable cover to prevent accidental fires and/or burns and unsafe disposal of cigarette butts on the ground in the smoking area.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, observations and policy review, the facility failed to ensure its residents knew how to file a grievance (complaint or concern).

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff developed baseline care plans within 48 hours of admission and/or that the baseline care plans were provided to four Residents (#3, #29, #32 and #39) or their Representatives (if applicable), out of a total sample of 17 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff reviewed and revised the plan of care for six Residents (#2, #3, #15, #28, #32, and #48), out of a total of 17 residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#3) was free from significant medication errors, out of a total of 17 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff properly secured and stored prescription medication, as required. Specifically facility staff failed to 1.) keep a box of emergency medication locked up, and 2.) monitor the medication refrigerator temperatures regularly on one of two units inspected.

Inspectors wroteBased on observation and interview the facility failed to ensure that its staff stored food in accordance with professional standards for food service safety. Specifically, the facility staff: 1) did not properly seal and/or label/date food when opened, 2) did not thoroughly clean areas where food and dishware was stored, 3) did not store foods off the floor, and 4) did not dispose of food that had expired.

Inspectors wrote[NAME], [NAME] Based on record review and interview the facility failed to ensure its staff maintained complete, accurate and readily accessible medical records for four Residents (#15, #26, #29 and #39), out of 17 residents sampled.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1.) ensure staff reviewed their Infection Control Policies and Procedures at least annually to ensure policies and procedures are current, 2.) create written policies related to COVID-19 surveillance and symptom monitoring, 3.) implement their procedures for COVID-19 screening prior to each shift for staff, putting the facility at risk for transmission for COVID-19 within the facility, and 4.) ensure that staff monitored for signs and symptoms of COVID-19 every shift on a unit conducting outbreak testing for two Residents (#26 and #44), out of three total sampled residents, to stop the spread of COVID-19 infection.

Inspectors wroteBased on observations, interview and policy review, the facility failed to ensure its staff protected the privacy of one Resident (#48), out of a total of 17 sampled residents. Specifically, the facility staff hung a sign containing personal information about the Resident on a wall next to his/her bed in plain view.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff answered a call bell in a timely manner for one Resident (#54) who required physical assistance from staff, out of 17 total residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided the required transfer documentation to a receiving provider for one Resident (#28), out of a total of 17 sampled residents, putting the Resident at risk for complications and adverse events upon transfer to the receiving facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided the required notices of transfer or discharge to the Resident, his/her Representative (if applicable) and the State Long-Term Care Ombudsman for two Residents (#23 and #28), out of a total of 17 sampled residents, as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided the required notices of bed-hold policy and return to the Resident and/or their Representative (if applicable) for two Residents (#23 and #28), out of a total of 17 sampled residents, as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff completed Comprehensive Minimum Data Set (MDS) Assessments timely, as required, for two Residents (#1 and #3), out of a total of 17 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff accurately coded the Minimum Data Set (MDS) Assessments for two Residents (#34 and #44), out of a total sample of 17 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff developed and/or implemented the plan of care for three Residents (#2, #28 and #48), out of a total sample of 17 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff provided resident treatment and care in accordance with professional standards of practice for one Resident (#44), out of a total of 17 sampled residents. Specifically, the facility failed to ensure its staff provided a daily dressing change as ordered by the Physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff provided necessary foot care and treatment for one Resident (#36), out of a total of 17 sampled residents. Specifically, the facility failed to offer podiatry (a branch of medicine devoted to the study, diagnosis and treatment of foot problems and conditions related to the lower legs) services resulting in overgrown toenails and pain when wearing footwear. Review of the facility policy titled, Foot Care, revised March 2018, indicated the following: - Residents will receive appropriate care and treatment in order to maintain mobility and foot health. - Residents will be provided with foot care and treatment in accordance with professional standards of practice. Resident #36 was admitted to the facility in March 2022. Review of the current Physician's Orders included the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its staff provided services relative to limited range of motion for one Resident (#28), out of a total of 17 sampled residents. Specifically, the facility failed to assess and treat a contracture (a shortening and hardening of muscles, tendons, or other her tissue, often leading to deformity and rigidity of joints), to his/her right hand and wrist, putting him/her at risk for increased contractures and pain. Resident #28 was admitted to the facility in April 2022 with a diagnosis of Cerebral Palsy (a group of disorders that affect movement and muscle tone and can cause stiff muscles with exaggerated reflexes (spasticity), stiff muscles normal reflexes (rigidity) and variations in muscle tone, such as being too stiff or too floppy (mayoclinic.org)). [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure the environment remained free of accident hazards relative to smoking for one Resident (#23), out of a total of 17 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided appropriate care and services for an indwelling urinary catheter (a device placed into the bladder to allow urine to drain) for one Resident (#32) out of 17 sampled residents. Specifically, the facility staff failed to 1) ensure the Resident had a urology consultation as scheduled and 2) obtain appropriate Physician's Orders for urinary catheter care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician and/or Nursing staff addressed pharmacy recommendations timely for two Residents (#3 and #48), out of a total sample of 17 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain lab work as ordered by the Physician for one Resident (#34), out of a total sample of 17 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff assisted one Resident (#34) with the process for obtaining dentures, out of a total sample of 17 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure staff maintained a medical record that included documentation that residents were offered and received the pneumococcal immunization (a vaccine used to prevent possible life-threatening pneumonia) and/or did not receive the pneumococcal immunization for two Residents (#21 and #26), out of a total of five sampled residents.

Inspectors wroteBased on interview and record review the facility failed to: 1.) Develop a COVID-19 vaccination policy for its residents, and 2.) Maintain a medical record that included documentation that residents were offered and received and/or did not receive or refused recommended COVID-19 vaccinations for two Residents (#21 and #31) out of a total of five sampled residents.

Inspectors wroteBased on interview the facility failed to ensure staff developed written policies related to COVID-19 vaccination for its staff.