Poet's Seat Health Care Center

F-F690.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 42761

Residents Affected - Few Based 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.

Findings include:

Review of the facility's policy titled Output, Measuring and Recording, dated 2001 and revised October 2010, indicated the following:

-The purpose was to accurately determine the amount of urine that a resident excretes in a 24-hour period.

-The following information should be recorded . in the resident's medical record:

>The date and time the resident's urine output was measured and recorded.

>The amount (in mls [milliliters]) of output.

Review of the facility's policy titled Catheter Care, Urinary, dated 2001 and revised August 2022, indicated

the following:

-The purpose was to prevent urinary catheter associated complications.

-Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction.

Review of the Lippincott Manual of Nursing Practice - 12th Edition (2025) Unit VI - Renal, Genitourinary, and Reproductive Health, Chapter 17. Renal and Urinary Disorders Unit VI - Renal, Genitourinary, and Reproductive Health - TDS Health indicated the following:

-Oliguira (small volume of urine) is indicated by urinary output of 50 - 500 mls in a 24-hour period.

-Oliguria may result from Acute Renal Failure, Chronic Kidney Disease (Stage V), shock, dehydration, fluid and electrolyte imbalance, or obstruction.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -Report decrease in output.

Level of Harm - Minimal harm or Resident #12 was admitted to the facility in July 2024, with diagnoses including retention of urine and potential for actual harm obstructive and reflux uropathy.

Residents Affected - Few Review of Resident #12's Hospital Discharge/Transfer note, dated July 2024, indicated the following:

-The Resident had a chronic indwelling Foley catheter.

-The Resident was treated for urinary tract infection (UTI).

Review of Resident #12's Nursing Admission Summary Note, dated July 2024, indicated the following:

-The Resident arrived at the facility at approximately 4:30 P.M.

-The Resident was alert and oriented.

-The Resident arrived with a (urinary) catheter.

-The (urinary) catheter was chronic and would remain in place.

-The on-call Provider was notified when the Resident arrived at the facility and verified medications.

Further review of the Admission Summary Note failed to indicate specifications for the Resident's indwelling urinary catheter.

Review of Resident #12's Nursing Admission Evaluation, dated July 2024, indicated the following:

-The Resident was incontinent of urine.

-The Resident had burning, pain, or discomfort with urination.

-The Resident had recurrent UTIs.

-The Resident's urine was very cloudy or purulent (containing pus).

-The Resident was admitted with a Foley (also referred to as an indwelling urinary catheter) catheter.

-The Foley catheter size/type was unknown.

Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated Resident #12:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -was dependent for toilet hygiene.

Level of Harm - Minimal harm or -did not have an indwelling urinary catheter. potential for actual harm

Review of Resident #12's Care Plan Report indicated the following: Residents Affected - Few -The Resident was totally dependent for toileting (7/6/24).

-The Resident had a Foley catheter (7/6/24)

>Check for tubing kinks each shift per policy.

>Maintain Enhanced Barrier Precautions (EBP).

>Monitor and document output as per facility policy.

>Observe for/document pain/discomfort due to catheter.

>The Resident will be/remain free from catheter-related trauma through next review date (revised 7/28/24).

Review of Resident #12's Initial Encounter Summary Provider Progress Note, dated 7/9/24, indicated the following:

-The Resident had a chronic indwelling Foley catheter.

-The Resident had been treated in the hospital for a UTI.

-The Resident continued on treatment for UTI with an antibiotic medication, end date of 7/12/24.

-The Resident had chronic retention of urine.

Review of Resident #12's July 2024 Physician orders failed to indicate any orders relative to care of the Resident's indwelling urinary catheter.

Review of Resident #12's Nursing Note, written by Nurse #3 on 7/18/24 at 2:37 P.M., indicated the following:

-The Resident's output was around 100 cc (cubic centimeters- measurement of volume where one cc is equal to one milliliter) each shift for the last two days (less than 500 mls for each of two consecutive 24-hour periods).

-On-call Provider contacted and requested order for flush (irrigation).

-Waiting for response.

Review of Resident #12's clinical record failed to include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -any evidence that an order to flush the Resident's indwelling urinary catheter had been obtained.

Level of Harm - Minimal harm or -any evidence that instructions had been obtained relative to the Resident's urine output of approximately potential for actual harm 100 cc per shift.

Residents Affected - Few -any evidence the Resident's urinary output was routinely monitored.

Further review of Resident #12's clinical record indicated the following instructions for care of the Resident's indwelling urinary catheter were not obtained until 8/7/24 (more than one month after admission to the facility):

-Catheter leg strap or catheter secure device in place every shift.

-Change Foley every three months and as needed .

-Empty Foley catheter bag every shift.

-Foley catheter care every shift for urinary elimination.

-Foley catheter size 18 F (French: catheter sizing), balloon size 30 ml.

-May irrigate or flush catheter with 60 cc of (normal saline) as needed

>Resistance (was there resistance?)

>Return (+ or -)

>Sediment (was there sediment?)

>Color (describe color of return)

On 5/22/25 at 8:37 A.M., the surveyor observed the following:

-Resident #12 was lying in bed.

-The Resident's urinary catheter tubing was visible, extending out from under the Resident's blankets and led to a collection bag that was positioned below the level of the Resident's bladder and covered by a privacy bag.

-Clear yellow urine was observed moving through the tube into the collection bag.

During an interview on 5/28/25 at 10:05 A.M., Resident #12 said shortly after he/she was admitted to the facility, his/her catheter was not draining properly. Resident #12 said that staff at the facility cleaned the catheter to get it to drain. When the surveyor asked how staff cleaned the catheter, the Resident said the staff used a tube of something and pushed it in. Resident #12 further said after staff cleaned the catheter, the catheter drained properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During an interview on 5/28/25 at 9:10 A.M., the Director of Nursing (DON) said when Resident #12 was admitted to the facility with an indwelling urinary catheter, the admitting Nurse should have assessed the Level of Harm - Minimal harm or Resident's catheter in order to identify the type and size of catheter that was in place. The DON said the potential for actual harm following orders should have been requested from the Physician and should have been entered into the Resident's electronic health record (EHR) for catheter care and services: Residents Affected - Few -the type and size of the catheter.

-the balloon size for the catheter.

-frequency for catheter care to be provided.

-catheter change frequency.

-an as needed (PRN) order to include instructions, including flushing and changing the catheter, to address catheter associated complications.

The DON also said that residents with chronic indwelling urinary catheters would not always be monitored for fluid intake and would be routinely monitored for urinary output. The DON said monitoring urinary output was important to ensure the Resident's catheter was functioning properly.

During a follow-up interview on 5/28/25 at 10:15 A.M., the DON also said when Resident #12 had 100 cc of urine output, it would indicate a potential complication with the Foley catheter and should have been assessed and reported to the Provider right away to avoid complications such as catheter tube kinking or urine obstruction. The DON said there were no orders in place for care of Resident #12's indwelling urinary catheter when the reduced urine output was identified, and she was unable to identify the intervention provided to address the Resident's low urine output. The DON also said waiting two days to address low urinary catheter output was concerning and that staff should have assessed Resident #12's urinary catheter status sooner and obtained instructions timely to address the low urine output.

During an interview on 5/28/25 at 3:33 P.M., Nurse #3 said she could not remember the exact date, but she had worked at the facility with Resident #12 when the Resident experienced reduced urine output for a period of two days. Nurse #3 said she contacted the on-call Provider and that she could not recall whether

the on-call Provider had returned her call. Nurse #3 said she could not recall what she did to resolve the Resident's reduced urine output, and that if the on-call Provider had provided instructions, Nurse #3 would have included the instructions in a Progress Note and Physician order in the Resident's clinical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52485

Residents Affected - Few 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.

Findings include:

Review of the facility policy titled Administering Medications version 2.1, dated 2001 and revised April 2019, indicated but was not limited to the following:

-Policy Statement:

>Medications are administered in a safe and timely manner, and as prescribed.

>Medications are administered in accordance with prescriber orders, including any required time frame.

>Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .

Review of the facility policy titled Pain-Clinical Protocol version 2.2, dated 2001 and revised October 2022, indicated but was not limited to the following:

-Assessment and Recognition:

<The physician and staff will identify individuals who have pain or who are at risk for having pain.

<The nursing staff will assess each individual for pain .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain.

-Treatment/Management:

<With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment .

-The physician will order .medication interventions to address the individual's pain.

Review of the facility policy titled Medication Orders, dated 2006 and revised January 2018, indicated but was not limited to the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 -Controlled Substance Prescriptions:

Level of Harm - Actual harm >The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not, or will not be available. Residents Affected - Few Resident #13 was admitted to the facility in July 2024, with diagnoses including dorsalgia (back pain), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain), low back pain, other chronic pain, and polyneuropathy (disease affecting peripheral nerves resulting in various symptoms including pain).

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #13:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) Assessment score of 15 out of a possible score of 15.

-was prescribed a scheduled pain medication regimen.

-had presence of pain almost constantly, which frequently affected his/her sleep.

-pain interfered with day-to-day activities frequently.

-pain intensity was a seven out of 10.

During an interview on 5/23/25 at 10:00 A.M., Resident #13 said he/she had issues getting his/her scheduled Oxycodone medication. Resident #13 said it had been an issue that the pain medication was not always available several times. Resident #13 said that he/she had gone anywhere from 12 to 18 hours without the pain medication at times. 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. Resident #13 said no alternate options to manage his/her pain were discussed or offered to him/her at the times when the Oxycodone medication was not available to be administered. Resident #13 also said he/she wanted to receive the Oxycodone medication as prescribed and did not want to experience any more missed doses.

During an interview on 5/27/25 at 11:55 A.M., Resident #13's Advocate said the concern related to the unavailability of Oxycodone medication started on 7/31/24. The Resident's Advocate provided nine dates that he/she documented between 7/31/24 and 4/13/25 on which the Oxycodone medication was not available to the Resident. The Resident's Advocate said he/she had attended care plan meetings and had discussed the concern regarding the unavailability of Oxycodone medication with nursing staff. The Resident's Advocate said the most recent care plan meeting during which the concern was discussed was

on 2/11/25. The Resident's Advocate said the facility did not state what actions were going to be taken to address the concern regarding the availability of the Resident's Oxycodone medication.

Review of Resident #13's current active Care Plans failed to indicate any care plans relative to pain management.

Review of Resident #13's Physician Orders between 7/29/24 and 12/31/24 indicated the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 -Oxycodone HCl oral tablet 10 milligrams (mg). Give 1 tablet by mouth every 4 hours for pain. Start date 7/29/24, End date 10/18/24. Level of Harm - Actual harm -Oxycodone HCl oral tablet 5 mg. Give 1 tablet by mouth every 12 hours as needed (PRN) for pain. Start Residents Affected - Few date 7/29/24, End date 8/10/24.

-Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 10/19/24, End date 12/3/24.

-Oxycodone HCl oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed (PRN) for moderate pain AND give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 12/3/24, End date 12/24/24.

-Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every 4 hours for pain. Start date 12/24/24.

-Acetaminophen tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed (PRN) for pain. Do not exceed 3 grams of Acetaminophen in 24 hours. Start date 7/29/24.

-Monitor for pain every shift using standard pain scale 0-10 (commonly used tool to assess pain intensity, where zero indicates no pain, and 10 indicates the worst pain imaginable) every shift for pain monitoring. Start date 7/29/24, End date 9/7/24.

-Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24.

Review of Resident #13's Medication Administration Record (MAR) dated July 2024 and the correlating Controlled Substance Log indicated the following:

-Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 7/31/24 due to the medication not being available.

>Resident #13's pain scale was documented as follows on 7/31/24:

-At 12:00 A.M. (Resident reported pain level: zero out of 10)

-at 4:00 A.M. (Resident reported a pain level of 10 out of 10)

-at 8:00 A.M. (Resident reported a pain level of 10 out of 10)

-Review of the medical record failed to indicate that the Provider was notified that the Oxycodone medication was unavailable to administer to Resident #13, or that any non-pharmacological intervention was offered.

-The first dose of Oxycodone medication was administered to the Resident on 7/31/24 at 10:00 A.M. (14 hours since the last administered dose).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Review of Resident #13's MAR dated September 2024, correlating Controlled Substance Logs, On-call Provider Log, and Nursing Notes indicated the following: Level of Harm - Actual harm -Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., Residents Affected - Few 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 8:00 P.M. on 9/20/24, and 12:00 A.M., and 4:00 A.M. on 9/21/24 due to the medication not being available.

>Resident #13's pain scale was documented as follows on 9/20/24 and 9/21/24:

-At 8:00 P.M. on 9/20/24 (Resident reported a pain level of eight out of 10)

-At 12:00 A.M. on 9/21/24 (Resident reported a pain level of 10 out of 10)

-At 4:00 A.M. on 9/21/24 (Resident reported a pain level of 10 out of 10)

-The facility staff contacted the on-call Provider on 9/20/24 at 10:38 P.M., regarding the need to obtain a new prescription of Oxycodone. The medical record documentation failed to indicate that a discussion occurred with the Provider regarding the Resident's pain assessment or the unavailability of the Resident's scheduled Oxycodone medication at the time the Provider was contacted.

-A Nursing Note written on 9/21/24 at 3:30 A.M., indicated that the on-call Provider was to contact the pharmacy to provide an order to obtain the Oxycodone medication from the pyxis (machine that is utilized to dispense an emergency supply of medication). The Nursing documentation failed to indicate that the facility accessed the pyxis at that time and administered the scheduled Oxycodone medication to the Resident.

-The first dose of Oxycodone medication was administered to the Resident on 9/21/24 at 9:40 A.M. (17 hours since the last administered dose).

Review of Resident #13's MAR dated October 2024, correlating Controlled Substance Logs, and Nursing Notes indicated the following:

-The Resident's supply of Oxycodone was exhausted at 8:15 P.M. on 10/17/24.

-Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) was not administered at 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 10/18/24 due to the medication not being available.

>Resident #13's pain scale was documented as follows on 10/18/24:

-At 12:00 A.M. (Resident reported a pain level of two out of 10)

-At 4:00 A.M. (Resident reported a pain level of five out of 10)

-At 8:00 A.M. (Resident reported a pain level of 10 out of 10)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 -A Nursing Note written on 10/18/24 at 4:44 A.M., indicated the on-call Provider was contacted at that time for a new Oxycodone prescription and pyxis access. (Five hours since the Resident's missed dose of Level of Harm - Actual harm scheduled Oxycodone)

Residents Affected - Few -The first dose of Oxycodone medication was administered to the Resident on 10/18/24, and documented for

the 8:00 A.M. dose (12 hours since the last administered dose).

Review of Resident #13's MAR dated November 2024, and the correlating Controlled Substance Log indicated the following:

-Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 P.M. on 11/13/24, and 12:00 A.M., 4:00 A.M., and 8:00 A.M. on 11/14/24 due to the medication not being available.

>Resident #13's pain scale was documented as follows on 11/13/24 and 11/14/24:

-At 8:00 P.M. on 11/13/24 (Resident reported a pain level of zero out of 10)

-At 12:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10)

-At 4:00 A.M. on 11/14/24 (Resident reported a pain level of zero out of 10)

-At 8:00 A.M. on 11/14/24 (Resident reported a pain level of 10 out of 10)

-Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that any non-pharmacological intervention was offered to the Resident.

-Acetaminophen 650 mg was administered as needed (PRN) on 11/14/24 at 8:08 A.M.

-The first dose of Oxycodone medication was administered to the Resident on 11/14/24 at 9:15 A.M. (17 hours since the last administered dose.)

-The Resident reported a pain level of three out of 10 on 11/14/24 at 12:58 P.M.

Review of Resident #13's MAR dated December 2024, and the correlating Controlled Substance Logs indicated the following:

-Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). Give 2 tablets to equal 10 mg dose was not administered at 8:00 A.M. on 12/24/24 due to the medication not being available.

-Oxycodone HCl oral tablet 10 mg. Give 1 tablet by mouth every 4 hours for pain (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.). was not administered at 12:00 P.M. on 12/24/24 due to the medication not being available.

>Resident #13's pain scale was documented as follows on 12/24/24:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 -At 8:00 A.M. on 12/24/24 (Resident reported a pain level of eight out of 10)

Level of Harm - Actual harm -At 12:00 P.M. on 12/24/24 (Resident reported a pain level of nine out of 10)

Residents Affected - Few -The Resident was offered Acetaminophen as needed (PRN) on 12/24/24 at 10:42 A.M., and declined.

-Review of the medical record failed to indicate that the Provider was notified that the scheduled Oxycodone medication was unavailable, or that any non-pharmacological intervention was offered to the Resident.

-The first dose of Oxycodone medication was administered to the Resident on 12/24/24 at 4:00 P.M. since

the first missed dose at 8:00 A.M. (10 hours since the last administered dose.)

During an interview on 5/27/25 at 11:51 A.M., Nurse Practitioner (NP) #1 said when a medication was not available to administer as ordered the Nurse should notify the Provider. NP #1 said the Provider can then give an order to hold if appropriate or can provide an order to administer an alternative medication from the emergency supply. NP #1 said she was not aware of a chronic issue regarding the unavailability of Resident #13's prescribed Oxycodone medication. NP #1 said nursing staff informed NP #1 when the Resident was admitted to the facility that the Resident's pain management interventions were not effective. NP #1 said she discussed with the Resident the option to be prescribed long-acting Oxycodone, but the Resident declined

the long-acting Oxycodone order and stated that his/her stomach could not tolerate this medication. 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.

During an interview on 5/27/25 at 4:30 P.M., the Director of Nursing (DON) said she was not aware of any times that Resident #13 did not have Oxycodone medication available for administration. The DON further said she also found that residents' medications were not always re-ordered timely.

During an interview on 5/28/25 at 9:10 A.M., the DON said the expectation is that medications are re-ordered by licensed nursing staff when the medication reached the red line (indicates medication level is running low and should be re-ordered) on the blister pack to allow the pharmacy time to refill the medication so that residents' medications were available to administer as ordered.

During an interview on 5/28/25 at 10:35 A.M., the DON said if a scheduled pain medication was not available for administration, the resident should be assessed for pain and asked whether they wanted to wait for the ordered medication to be delivered from the pharmacy or whether they wanted the Nurse to contact the Provider to request an alternative medication.

During an interview on 5/28/25 at 11:06 A.M., the Physician said that the facility should be notifying the Provider when a medication was not available for administration. The Physician also said if multiple doses in

a row of a scheduled short-acting pain medication were not administered to a resident, he would expect the resident to have increased pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 During an interview on 5/28/25 at 1:10 P.M., Resident #13 said that most of the time, his/her pain level was between a seven and nine out of 10. Resident #13 said when he/she swells it really hurt, and sometimes Level of Harm - Actual harm he/she curled up in a little ball. 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. Resident Residents Affected - Few #13 said it depended on which Nurse cared for him/her as to whether he/she would be offered as needed pain medications. Resident #13 said it took at least one hour for any pain medication being administered to bring down his/her pain level.

Please Refer to

F-F697.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42690 potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure one Resident (#32) out of Residents Affected - Few 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.

Findings include:

Review of the facility policy titled Use of Restraints, revised 4/2017, indicated the following:

-Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjusted to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body.

-Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted:

>Placing a resident in a chair that prevents the resident from rising.

>Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising.

Resident #32 was admitted to the facility in February 2023, with diagnoses including syncope and collapse and Dementia with behavioral disturbances.

Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated the following:

-Resident's behavior (rejection of care or wandering) had worsened since the prior assessment conducted 9/11/24.

-No impairment for upper extremity range of motion.

-No impairment for lower extremity range of motion.

-Required substantial/maximal assistance to sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed).

-Required substantial/maximal assistance to walk 10 feet.

-was dependent to wheel 50 feet with two turns while in the wheelchair

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Review of Resident #32's Fall Care Plan, initiated on 2/24/23, indicated the following interventions:

Level of Harm - Minimal harm or -If Resident is awake, keep him/her in the area of staff for safe monitoring, secondary [sic] if he/she is not potential for actual harm tired he/she will attempt to get up independently, updated on 7/14/24.

Residents Affected - Few Review of a Nurses' Note dated 4/3/25, indicated Resident #32 continued to stand up and required frequent direction to sit in his/her chair.

Review of a Nurses Note dated 4/6/25, indicated in part:

- .staff redirecting the Resident from standing up in his/her wheelchair

- .Resident attempted to stand up from the wheelchair seven times.

-Monitored for safety because he/she would not sit still.

Review of the Physical Restraint assessment dated [DATE REDACTED], indicated Resident #32:

-had a history of being impulsive and impaired safety awareness due to significant cognitive deficits and agitation.

On 5/27/25 the surveyor observed the following at 1:22 P.M., 2:18 P.M., 2:57 P.M., 3:03 P.M., 3:12 P.M., 3:26 P.M., 3:30 P.M., and 3:37 P.M.:

-Resident #32 to be sleeping in his/her wheelchair located next to the nurses station, with both feet flat on

the floor and pushed up to a counter with his/her upper body approximately six inches away from the counters' edge, and the Resident's legs under the counter.

-The wheelchair had anti-tippers (a safety accessory attached to the frame of the wheelchair, typically near

the rear wheels that extend outward, designed to prevent the wheelchair from tipping backward).

-The wheelchair had an anti-rollback (a safety accessory attached to the wheelchair to prevent wheelchair users from rolling backwards in any situation) devices installed.

-The wheelchair brakes were engaged, restricting the Resident's mobility and ability to move him/herself away from the counter or to move freely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During an interview on 5/27/25 at 3:03 P.M., with Certified Nurses Aide (CNA) #3 and CNA #2, CNA #3 said

she thought Resident #32 might be able to lock and unlock the brakes depending on the day but she was not Level of Harm - Minimal harm or sure. CNA #3 said the Resident preferred to be seated at the counter and if he/she was not seated there, the potential for actual harm Resident would become confused and try to get up from the wheelchair. CNA #3 said when the Resident was anxious or attempted to get up from the wheelchair, the staff would take him/her for a walk or to the Residents Affected - Few bathroom. CNA #3 said Resident # 32's daughter came in for lunch today and sat with the Resident during lunch. CNA #3 said staff had brought the Resident to the bathroom after lunch, placed him/her back at the counter in the hallway near the nurses station where he/she fell asleep shortly after. CNA #3 said if the staff were to put him/her to bed, the Resident would climb out, so CNA #3 felt it was safer for the Resident to be situated where he/she was (at the counter). When the surveyor asked about the wheelchair brakes being engaged, CNA #3 said the brakes should not be on, that the Resident had anti-tippers, and an anti-rollback device on the chair and with his/her energy level today, the Resident would not be able to unlock the brakes him/herself or free him/herself from his/her current position. CNA #2 said she thought the Resident's daughter may have placed the Resident in that position and must have put his/her brakes on when she left.

The surveyor observed at the end of the interviews on 5/27/25 at 3:12 P.M., that neither CNA #3 nor CNA #2, unlocked the Resident's wheelchair brakes, leaving Resident #32 pushed up to the nurses station counter with the wheelchair brakes engaged, restricting the Resident to this position and unable to move freely.

On 5/27/25 at 3:12 P.M., the surveyor observed a staff member rubbing Resident #32's back. Resident #32 awoke and began to engage with the staff. The staff member provided a baby doll with clothing and a baby doll seat, which the Resident began to engage with. The staff member walked away from the Resident, and

the wheelchair brakes remained engaged.

During an interview on 5/27/25 at 3:37 P.M., the Director of Nursing (DON) said that the Resident preferred to be seated at the counter. The DON said in the Resident's current position, he/she would not be able to independently move him/herself but should be able to. The DON unlocked the wheelchair brakes and said

the brakes should not be locked, as the Resident had the anti-rollback wheels and the anti-tippers in place to prevent the wheelchair from tipping backwards or rolling away if he/she should stand up. The DON said the Resident does attempt to stand routinely and felt that the staff most likely thought they were doing the right thing in terms of safety. The DON further said that the Resident's current position with locked brakes did restrict the Resident's movement and the brakes should not have been engaged while the Resident was placed at the counter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Potential for 42761 minimal harm Based on observation, interviews, and record reviews, the facility failed to accurately assess the urinary Residents Affected - Some 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.

Findings include:

Resident #12 was admitted to the facility in July 2024, with diagnoses including retention of urine and obstructive and reflux uropathy.

Review of Resident #12's Hospital Discharge/Transfer note, dated July 2024, indicated the following:

-The Resident had a chronic indwelling Foley catheter.

-The Resident was treated for urinary tract infection (UTI).

Review of Resident #12's Admission Summary Note, dated July 2024, indicated the following:

-The Resident arrived at the facility with a catheter.

-The catheter was chronic and would remain in place.

Review of the Minimum Data Set (MDS) Assessment, dated 7/10/24, indicated Resident #12:

-was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points.

-was dependent for toilet hygiene.

-did not have an indwelling urinary catheter.

On 5/22/25 at 8:37 A.M., the surveyor observed the following:

-Resident #12 was lying in bed.

-The Resident's urinary catheter tubing was visible, extending out from under the Resident's blankets and led to a collection bag that was covered by a privacy bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 -Clear yellow urine was observed moving through the urinary catheter tubing into the collection bag.

Level of Harm - Potential for During an interview at the time, Resident #12 said that he/she had an indwelling urinary catheter which had minimal harm been in place since prior to being admitted to the facility.

Residents Affected - Some During an interview on 5/23/25 at 1:30 P.M., the MDS Nurse said she reviewed Resident #12's clinical record and the Resident was admitted to the facility with an indwelling urinary catheter. The MDS Nurse said the indwelling urinary catheter was in place at the time of the comprehensive MDS Assessment, dated 7/10/24.

The MDS Nurse said that the MDS was inaccurately coded. The MDS Nurse also said the MDS Assessment should have been coded to indicate the Resident had an indwelling urinary catheter.

Please Refer to

F-F842.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52485

Residents Affected - Few Based 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.

Findings include:

Review of the facility policy titled Administering Medications version 2.1, dated 2001 and revised in April 2019, indicated but was not limited to the following:

-Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.

-The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Review of the facility policy titled Pain-Clinical Protocol version 2.2, dated 2001 and revised in October 2022, indicated but was not limited to the following:

-Assessment and Recognition:

- .Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.

-Treatment/Management:

-With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment .

-The physician will order .medication interventions to address the individual's pain.

Resident #13 was admitted to the facility in July 2024, with diagnoses including dorsalgia (back pain), fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain), low back pain, other chronic pain, and polyneuropathy (disease affecting peripheral nerves resulting in various symptoms including pain).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED], indicated Resident #13:

Level of Harm - Minimal harm or -scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam, indicating the potential for actual harm Resident was cognitively intact.

Residents Affected - Few -was prescribed a scheduled pain medication regimen.

-had presence of pain almost constantly, which frequently effected his/her sleep.

-pain interfered with day-to-day activities frequently.

-pain intensity was a seven out of 10 on the standard pain scale 0-10 (commonly used tool to assess pain intensity, where zero indicates no pain, and 10 indicates the worst pain imaginable)

Review of Resident #13's Physician Orders between 7/29/24 and 5/28/25 indicated but was not limited to the following:

-Oxycodone HCl oral tablet 5 mg. Give 1 tablet by mouth every 12 hours as needed for pain. Start date 7/29/24, End date 8/10/24.

-Oxycodone HCl oral tablet 10 milligrams (mg). Give 1 tablet by mouth every 4 hours for pain. Start date 7/29/24, End date 10/18/24.

-Oxycodone HCl oral tablet 5 mg. Give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 10/19/24, End date 12/3/24.

-Oxycodone HCl oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed for moderate pain AND give 10 mg by mouth every 4 hours for pain. Give 2 tablets to equal 10 mg dose. Start date 12/3/24, End date 12/24/24.

-Oxycodone HCl oral tablet 10 mg. Give 10 mg by mouth every 4 hours for pain. Start date 12/24/24.

-Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24, End date 9/7/24.

-Monitor for pain every shift using standard pain scale 0-10 every shift for pain monitoring. Start date 7/29/24.

1. Review of Resident #13's August 2024 and November 2024 MARs, and the correlating Controlled Substance Log and Nursing Notes indicated the following:

-8/7/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 4:00 A.M.

-The Controlled Substance Log indicated that Oxycodone 10 mg was administered to the Resident at 4:55 A. M. on 8/7/24.

-11/13/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 8:00 P.M.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 225360 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225360 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Poet's Seat Healthcare Center 359 High Street Greenfield, MA 01301

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 -11/21/24: The MAR failed to indicate documentation for the scheduled Oxycodone dose at 4:00 A.M.

Level of Harm - Minimal harm or -The Controlled Substance Logs indicated that Oxycodone 10 mg was administered to the Resident at 5:35 potential for actual harm A.M. on 11/21/24.

Residents Affected - Few -Documentation of Nursing Notes failed to indicate the status of administration of the 8:00 P.M. dose of Oxycodone on 11/13/24 and the 4:00 A.M. dose of Oxycodone on 11/21/24.

During an interview on 5/28/25 at 8:15 A.M., with the Administrator and the Director of Nursing (DON), the Administrator said the 4:00 A.M. dose on 8/7/24 and the 4:00 A.M. dose on 11/21/24 were not documented

in the MARs, and were documented in the Controlled Substance Logs. The Administrator said she was unable to verify whether the 8:00 P.M. dose on 11/13/24 had been administered to the Resident as ordered by the Physician. The DON said when a medication is documented in the Controlled Substance Log, it should be reflected as having been administered in the MAR.

2. On 5/27/25 at 12:09 P.M. surveyor #1 and surveyor #2 observed Nurse #2 administer the 12:00 P.M. dose of scheduled Oxycodone medication to Resident #13. Nurse #2 asked the Resident whether he/she had pain, and the Resident said that he/she did have pain. Nurse #2 was not observed to ask the Resident a pain level according to the standard pain scale (0-10) as ordered.

Review of Resident #13's May 2025 MAR, indicated documentation the Resident's pain score was zero out of 10 for the 12:00 P.M. dose of scheduled Oxycodone on 5/27/25.

During an interview on 5/28/25 at 7:22 A.M., Nurse #2 said she recalled providing Resident #13 his/her 12:00 P.M. dose of Oxycodone on 5/27/25. Nurse #2 said she recalled the Resident saying at that time that there is always something hurting him/her. Nurse #2 reviewed the May 2025 MAR and said that she documented a zero out of 10 for the Resident's pain at that time. Nurse #2 said she could have asked the Resident what his/her pain score was on the standard pain scale 0-10. Nurse #2 said she should have asked the Resident about his/her pain level but did not ask. Nurse #2 said that it is important to document an accurate pain score because the Provider needs to know the effectiveness of the treatment plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 225360