Federal inspectors found the facility failed to manage pain appropriately for the resident, who has fibromyalgia, back pain, and polyneuropathy. The resident told inspectors he had "gone anywhere from 12 to 18 hours without the pain medication" on multiple occasions between July 2024 and April 2025.
"At this time, the Resident began to cry and said that when he/she went without the scheduled Oxycodone medication, he/she experienced an increase in pain," the inspection report states.
The resident's advocate documented nine separate dates when the oxycodone was unavailable. Staff provided no alternative pain management during these episodes.
On July 31, 2024, just two days after admission, the facility ran out of the resident's 10-milligram oxycodone tablets. The medication was scheduled every four hours around the clock. Staff missed the midnight, 4 a.m., and 8 a.m. doses.
The resident's pain escalated dramatically. At midnight, they reported zero pain. By 4 a.m., pain had spiked to 10 out of 10 — the maximum level. At 8 a.m., pain remained at 10 out of 10. The first dose wasn't administered until 10 a.m., 14 hours after the last successful dose.
Records show no evidence that staff contacted the physician about the unavailable medication or offered any non-drug pain relief measures.
The pattern repeated throughout the resident's stay. In September 2024, the facility again ran out of oxycodone. Staff missed doses at 8 p.m. on September 20 and midnight and 4 a.m. on September 21. The resident reported pain levels of eight and 10 out of 10 during the missed doses.
Staff contacted the on-call provider at 10:38 p.m. on September 20 about obtaining a new prescription. A nursing note indicated the provider would contact the pharmacy to authorize emergency medication from the facility's automated dispensing machine. But records show staff never accessed the emergency supply that night.
The resident didn't receive medication until 9:40 a.m. on September 21 — 17 hours after the last dose.
Similar shortages occurred in October, November, and December 2024. During the October episode, the resident's pain climbed from two out of 10 at midnight to 10 out of 10 by 8 a.m. after missing three consecutive doses.
In November, after 17 hours without medication, staff finally offered acetaminophen as an alternative. The resident's pain dropped from 10 to three after receiving the delayed oxycodone dose.
The resident told inspectors that "most of the time, his/her pain level was between a seven and nine out of 10." They described curling "up in a little ball" when swelling increased pain. "Resident #13 said he/she was hurting all the time, and that his/her body was in pain from his/her head to his/her feet, that was why he/she needed medication every four hours."
The facility's nurse practitioner told inspectors she wasn't aware of chronic oxycodone shortages. She said she had offered the resident long-acting pain medication, but they declined, saying their stomach couldn't tolerate it. "NP #1 said the Resident is very particular about what medications he/she wanted and at what time he/she wanted to take the prescribed medications."
The Director of Nursing initially denied knowledge of medication shortages but later acknowledged that "residents' medications were not always re-ordered timely." She said staff should reorder medications when blister packs reach the "red line" indicating low supply.
The facility's physician said he expected residents to experience increased pain when missing multiple doses of short-acting pain medication. He said staff should notify providers immediately when medications are unavailable.
Inspectors also found the facility failed to properly assess another resident's urinary catheter upon admission. The resident arrived in July 2024 with a chronic indwelling catheter but staff never determined the catheter's size, type, or balloon specifications.
Two weeks after admission, the resident's urine output dropped to about 100 cubic centimeters per shift for two consecutive days — well below normal levels that could indicate catheter blockage or other complications. A nurse contacted the on-call provider requesting an order to flush the catheter but records don't show whether instructions were received or what intervention resolved the low output.
The facility didn't obtain proper catheter care orders until August 7, 2024 — more than a month after admission. Those orders specified an 18 French catheter with a 30-milliliter balloon and instructions for irrigation with normal saline as needed.
The resident told inspectors that shortly after admission, "his/her catheter was not draining properly" and staff "cleaned the catheter to get it to drain" using "a tube of something and pushed it in."
The Director of Nursing acknowledged that admitting nurses should assess catheter specifications immediately and obtain appropriate physician orders for care, monitoring, and emergency interventions. She called the two-day delay in addressing low urine output "concerning" and said staff should have acted sooner to prevent complications.
The resident with catheter problems was cognitively intact and dependent on staff for all toilet-related care. Their admission assessment noted cloudy, purulent urine and a history of recurrent urinary tract infections — conditions requiring careful monitoring that the delayed orders prevented.
Both violations reflect what inspectors characterized as systemic failures in medication management and clinical assessment that put residents at risk for preventable complications and suffering.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Poet's Seat Healthcare Center from 2025-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
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