Alden Poplar Creek Rehab & HCC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure no delay in care and treatment to a resident with unwitnessed fall that was later diagnosed with fractured left elbow. The facility also failed to revise resident comprehensive care plan in a timely manner for cast management and ADLs (Activity of daily living) limitation affected by cast on left elbow due to fracture. This deficiency affects one (R1) of three residents reviewed for Fall management.

Inspectors wroteBased on observation, interview, and record review, the facility failed properly store food in a manner to prevent cross-contamination and failed to label prepared foods stored in the refrigerator. This applies to all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's provider of elevated blood glucose levels. This applies to 1 of 1 residents (R34) reviewed for notification in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound care was provided in a manner to prevent contamination of the wound bed for 1 of 8 residents (R144) reviewed for pressure injuries in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ordered treatment for contractures. This applies to 1 of 1 residents (R89) reviewed for range of motion in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer a resident in a safe manner. This applies to one two (R136) reviewed for safety in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address a recommendation by the Registered Dietitian to increase a resident's enteral feeding for 1 of 4 residents (R5) reviewed for tube feedings in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed for the administration of oxygen for 1 of 1 resident (R122) reviewed for oxygen services in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove soiled gloves before touching any other clean surfaces. This applies to one of Six residents (R136) reviewed for infection control in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with severe cognitive impairment and a history of wandering was supervised to prevent elopement. This failure resulted in R1 eloping from a secured memory care unit, exiting the building without staff identifying and preventing R1 from eloping. R1 exited the building and ambulated without her walker crossing a six-lane busy intersection and was found approximately 0.8 miles away from the facility wandering outside of the local grocery store. This applies to 1 of 6 residents (R1) reviewed for safety in the sample of 6. The Immediate Jeopardy began on 7/1/25, when R1 got on the elevators with another resident's family on the secured memory unit. R1 exited the first-floor elevators and ambulated out the front entrance without staff identifying R1 was eloping the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the decisions of a hospice resident's health care Power of Attorney for 1 of 3 residents reviewed for rights exercised by a resident's representative in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to designate a staff member, or implement a process, to ensure effective, ongoing communication and collaboration between the facility, a hospice resident's Power of Attorney for health care (POA), and the hospice provider. The facility failed to ensure facility staff had access to and reviewed a resident's hospice plan of care and hospice progress notes. These failures apply to 1 of 3 residents (R1) reviewed for care and services of a hospice resident in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician. This applies to 1 of 28 residents (R96) reviewed for Advanced Directives in the sample if 28.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by reporting and investigating allegations of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff reported allegations of sexual abuse to the Administrator immediately. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of sexual abuse. This applies to 2 of 28 residents (R56 & R115) reviewed for abuse in the sample of 28.

Inspectors wroteBased on observation, interview, and record revie,w the facility failed to ensure schedule II controlled substances were stored in a separately locked compartment for 2 of 28 residents (R54 and R92) reviewed for medication storage in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn when providing care to a resident on enhanced barrier precautions (EBP) for 1 of 28 residents (R78) reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received an influenza vaccine following admission to the facility. The facility also failed to ensure a resident was offered a second pneumonia vaccine. This applies to 2 of 5 residents (R116, R90) reviewed for immunizations in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of sexual abuse were reported to the police for 1 of 3 residents (R1) reviewed for sexual abuse in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to release a resident's trust funds after discharge for 1 of 3 residents (R1) reviewed for trust funds in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a residents' care provider was notified after a resident received a Defebrilator Vest (DV) intervention (shock) which applies to 1 of 1 residents reviewed for physician notification in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility neglected to identify R1 had a defibrillator vest (DV), and failed to ensure facility staff were trained on the DV's set up, monitoring, functioning, and trouble shooting of the device which applies to 1 of 1 residents (R1) reviewed for neglect in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility to ensure a resident had ongoing monitoring after a Defibrillator Vest (DV) treatment (shock) was delivered, and failed to ensure a DV hotspot was set up to assist with remote monitoring which applies to 1 of 1 residents (R1) reviewed for quality of care in a sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to respect a resident's personal space when a staff member stored their bag in the resident's closet. This applies to 1 of 3 (R7) residents rights reviewed for staff behavior in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transport a resident in a manner to prevent him from falling out of the wheelchair. This applies to 1 of 4 residents (R6) reviewed for falls in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received a quarterly statement of their monthly Social Security stipend for five of five residents (R5, R28, R44, R81, R102) reviewed for Personal Funds in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that are totally dependent on staff for toileting/incontinence care for 2 of 26 residents (R103, R82) reviewed for ADLs in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement R13's Care Plan interventions to reduce pressure on her stage 3 pressure ulcer for 1 of 4 residents (R13) reviewed for Pressure ulcers in the sample of 26.