Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Poet's Seat Healthcare Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments and behavioral issues did not have comprehensive care plans addressing their needs, leading to incidents of inappropriate behavior. Despite documented histories of wandering, disrobing, and inappropriate touching, their care plans lacked specific interventions. Staff interviews revealed a lack of awareness about these deficiencies, indicating a failure to implement facility policies effectively.
Two residents with a history of wandering and inappropriate behaviors were inadequately supervised, leading to an incident where one resident was found in another's bed with clothing partially removed. Despite known behaviors, staff failed to provide sufficient supervision, resulting in a potential resident-to-resident altercation.
The facility failed to maintain kitchen equipment in a sanitary manner, with observations of dirty microwaves, ovens, food mixers, and an ice machine. Interviews revealed a lack of cleaning schedules and policies, and the ice machine had not been cleaned for several months, posing a risk of contamination.
The facility failed to issue a NOMNC and/or SNF ABN for two residents when their Medicare benefits ended, resulting in the residents not being informed about changes in billing and potential financial responsibilities.
The facility failed to investigate a fall event and implement interventions for a resident at risk of falling, and did not maintain or test a wander guard device for a resident at risk of elopement. These deficiencies highlight lapses in ensuring a safe environment for residents.
The facility failed to ensure that breakfast meals were served at a palatable temperature on the South Unit. Residents reported cold meals, and the Resident Council's concerns were not effectively addressed. A test tray tasting confirmed that the food was not served at appetizing temperatures, and no recent test tray audits were conducted.
The facility failed to implement smoking policies and maintain the smoking area. A resident with nicotine dependence and COPD was not assessed quarterly for safe smoking habits as required. Additionally, the smoking area was found littered with cigarette butts and an overfilled disposal receptacle, with no set cleaning schedule in place.
Failure to Implement Comprehensive Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents with severe cognitive impairments, leading to incidents of inappropriate behavior. Resident #1, who was admitted in March 2022, had a history of dementia, insomnia, and anxiety, and was known for wandering and disrobing in public. Despite these behaviors being documented in various assessments and notes, Resident #1's care plan did not include specific goals or interventions to address these issues. This lack of a tailored care plan resulted in an incident where Resident #1 was found in another resident's bed with their pull-up brief around their ankles. Similarly, Resident #2, also admitted in March 2022, had dementia with behavioral disturbances and was involved in an incident of inappropriate touching. Despite being referred to a physician for this behavior and being identified as requiring supervision, Resident #2's care plan lacked interventions to manage their inappropriate touching. The physician and behavioral health provider both noted that Resident #2's behaviors were related to their dementia and could be better managed with staff interventions rather than medication. Interviews with staff, including the Director of Nurses, revealed a lack of awareness regarding the absence of specific interventions in the care plans for both residents. The facility's policies on care planning and wandering were not effectively implemented, as evidenced by the incidents involving both residents. The failure to address these behaviors in the care plans highlights a significant deficiency in meeting the residents' needs and ensuring their safety.
Inadequate Supervision Leads to Resident Incident
Penalty
Summary
The facility failed to provide adequate supervision for two residents, both of whom had a history of wandering and inappropriate behaviors. Resident #1, who was severely cognitively impaired, was known to wander and exhibit intrusive behaviors, such as entering other residents' rooms. Resident #2, also severely cognitively impaired, had a history of inappropriate behaviors, including touching other residents. Despite these known behaviors, the facility did not ensure sufficient supervision to prevent potential resident-to-resident altercations. On the night of the incident, Resident #1 was found in Resident #2's bed with his pull-up brief around his ankles, while Resident #2 was standing nearby with his pants and underwear down. This situation occurred despite previous observations by staff of Resident #1 wandering into Resident #2's room multiple times that evening. Staff members, including a nurse and a CNA, were aware of the residents' behaviors but did not effectively communicate or act upon these observations to prevent the incident. The facility's staffing on the night of the incident included one nurse and one CNA per unit, with an additional nurse and CNA scheduled to float between units. However, the staff did not adequately supervise the residents, particularly those known to wander into other residents' rooms. The Director of Nurses and the Administrator acknowledged that both residents required supervision due to their behaviors, yet the staffing and supervision provided were insufficient to prevent the incident.
Failure to Maintain Kitchen Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to ensure that food served to the residents was prepared in accordance with professional standards for food service and safety. During an inspection of the main kitchen, the surveyor observed that the microwave, ovens, food mixer, and ice machine were not maintained in a clean and sanitary manner. The microwave had dried-on, splattered food particles, and both ovens contained large pieces of debris, baked-on food residue, and exposed copper wire and springs. The commercial food mixer had a sticky, brownish/black/orange substance on the hub, which caused particles to drop into the mixing bowl when touched. The ice machine had a long piece of plastic hanging over the ice and a brownish/orange, wet substance dripping into the ice. The cleaning log indicated that the ice machine was last cleaned several months prior, and the Director of Maintenance was unsure when it was last cleaned. Interviews with the Food Service Director (FSD) and dietary staff revealed that there was no cleaning/maintenance schedule for the kitchen, and staff cleaned areas only when they noticed they needed cleaning. The FSD was not aware of any facility policies related to kitchen cleaning and sanitation. The Director of Maintenance, responsible for cleaning the ice machine, admitted that he was unsure when it was last cleaned and acknowledged that the dark, wet substance in the ice machine could make residents sick. The FSD later provided a cleaning checklist, but it was not being utilized by the staff.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and/or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two residents. Specifically, Resident #12 did not receive a NOMNC or SNF ABN notice when their Medicare benefits ended on March 4, 2024. Similarly, Resident #36 did not receive a SNF ABN notice when their Medicare benefits ended on December 4, 2023. The absence of these notices means that the residents were not informed in advance about changes in their billing and potential financial responsibilities for services not covered by Medicare. During an interview, the Business Office Manager (BOM) confirmed that no NOMNC was issued for Resident #12 and acknowledged that it should have been issued at least two days prior to the last covered day on Medicare. The BOM also confirmed that both Resident #12 and Resident #36 remained in the facility after their Medicare benefits ended, and a SNF ABN was not issued to either resident. This failure to provide the required notices resulted in the residents not being fully informed about service-related changes and their appeal rights.
Failure to Prevent Accidents and Maintain Safety Devices
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards for two residents. For Resident #10, the facility did not investigate a fall event that occurred on 2/29/24, nor did they implement additional interventions to prevent further falls. The resident, who had a history of falls and was cognitively intact, experienced multiple falls, including an unwitnessed fall that resulted in a hospital visit. Despite these incidents, the facility did not update the resident's care plan with new fall prevention measures, and the Director of Nurses (DON) acknowledged the lack of investigation and intervention for the fall on 2/29/24. For Resident #46, the facility failed to provide maintenance and testing for a wander guard device, which is crucial for residents at risk of elopement. The resident, who was severely cognitively impaired and had a history of attempting to leave the facility, was observed wearing a wander guard device. However, there was no evidence in the clinical records, Medication Administration Record (MAR), or Treatment Administration Record (TAR) that the device had been regularly tested or maintained. Both the DON and Assistant Director of Nurses (ADON) confirmed that the required maintenance and testing were not documented or performed as needed. These deficiencies highlight the facility's failure to adhere to its own policies regarding fall prevention and the maintenance of safety devices. The lack of proper investigation, documentation, and intervention for Resident #10's falls, as well as the failure to maintain and test Resident #46's wander guard device, demonstrate significant lapses in ensuring a safe environment for residents at risk of accidents and elopement.
Failure to Serve Palatable Breakfast Meals
Penalty
Summary
The facility failed to ensure that breakfast meals were served at a palatable temperature on the South Unit. Residents reported that breakfast oatmeal was often cold, plates used to keep food warm were not effective, and breakfast meals were cold at least once a week. The Resident Council had raised concerns about cold food in their December meeting, but no effective follow-up actions were taken by the Food Service Director (FSD) to address these issues. The FSD provided logs showing that food left the kitchen at a hot temperature but did not assess the food temperature upon arrival at the units. During a test tray tasting conducted by the surveyor, it was found that the scrambled eggs and shredded potatoes were cool to the taste, and the oatmeal was only warm. The FSD admitted that no recent test tray audits had been conducted, and the Administrator confirmed that no follow-up actions or test tray audits were documented in response to the Resident Council's concerns. The facility did not provide any evidence of corrective actions by the end of the survey.
Failure to Implement Smoking Policies and Maintain Smoking Area
Penalty
Summary
The facility failed to implement smoking policies as required for one resident and did not maintain the resident smoking area in a safe, clean, and sanitary manner. Specifically, the facility staff did not ensure that smoking assessments and Resident Agreements for safe smoking habits were completed quarterly for a resident with nicotine dependence and Chronic Obstructive Pulmonary Disease (COPD). The resident's smoking abilities and habits were only assessed twice in the past year, contrary to the facility's policy requiring quarterly evaluations. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of awareness regarding the frequency of these evaluations, confirming the deficiency in adherence to the policy. Additionally, the facility did not establish a cleaning schedule for the smoking area, resulting in an unsafe and unsanitary environment. Observations revealed the smoking area littered with cigarette butts and an overfilled cigarette disposal receptacle with a missing cover. The DON acknowledged the area had not been cleaned recently and that maintenance should ensure regular cleaning and emptying of the receptacle. The Maintenance Director confirmed the absence of a set cleaning schedule and noted the area had not been maintained properly, further contributing to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charlene Manor Extended Care Facility | 2.1 mi | — | 3 | 0 |
| Regalcare At Greenfield | 2.3 mi | — | 0 | 0 |
| Vernon Green Nursing Home | 11.6 mi | — | 12 | 0 |
| Applewood Center | 14.9 mi | — | 0 | 0 |
| Quabbin Valley Healthcare | 16.1 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.