A list of the most recent deficiencies for Poet's Seat Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-08-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-28 | 2023-08-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-02 | 2022-12-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-02 | 2022-12-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-02 | 2022-12-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-02 | 2022-12-03 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-11-02 | 2022-12-03 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-02 | 2022-12-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-02 | 2022-12-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-02 | 2022-12-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-02 | 2022-12-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-02 | 2022-12-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide appropriate foot care. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-02 | 2022-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-02 | 2022-12-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-02 | 2022-12-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-02 | 2022-12-03 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-02 | 2022-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-02 | 2022-12-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-15 | 2022-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2022-11-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2022-11-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-02 | 2022-11-18 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-02 | 2022-11-18 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-02 | 2022-11-18 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-02 | 2022-11-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-25 | 2022-06-24 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-29 | 2021-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-29 | 2021-09-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-27 | 2021-09-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-27 | 2021-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-27 | 2021-09-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-27 | 2021-09-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-27 | 2021-09-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-27 | 2021-09-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-27 | 2021-09-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-27 | 2021-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-27 | 2021-09-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-27 | 2021-09-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-07-27 | 2021-08-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-22 | 2019-05-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-22 | 2019-05-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-22 | 2019-05-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-22 | 2019-05-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-22 | 2019-05-03 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-04-18 | 2019-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-18 | 2019-05-01 | N |
