Poplar Care Strategies

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 3 newly admitted residents reviewed. A basline care plan assessment was not completed and plan of care was not in place specific to the individualized resident needs. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent accident hazards for 2 of 3 residents reviewed for accidents. A resident with supplemental oxygen was placed in a room with another resident with a documented history of non-compliance with the facility's non-smoking policy, which included the possecion of a vape pen in the resident room. The resident was alleged to be smoking in the resident's shared restroom and smoke was observed coming from the restroom while an oxygen concentrator was running in the resident's room. (Resident B, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident receiving oxygen therapy had physician orders and a plan of care for the oxygen for 1 of 3 residents reviewed for oxygen therapy. A resident who routinely received supplemental oxygen had no physician's order to clarify the continuous need for oxygen therapy or for the amount of oxygen the resident required. (Resident B)Finding incudes:During an observation on 4/28/26 at 10:30 A.M., Resident B and Resident C were observed in the same room. Resident B was wearing supplemental oxygen received from an oxygen concentrator in the room and delivered via nasal cannula. During record review on 4/28/26 at 11:00 A.M., Resident B's diagnoses included, but was not limited to heart failure and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident privacy for 4 of 4 random observations. Staff did not knock on doors prior to entering, and doors and curtains were not closed during a wound dressing change. (Resident 21, Resident 3, Resident 9, Resident 10)

Inspectors wroteBased on interview and record review, the facility failed to ensure the Activity Director was certified for 1 of 1 Activity Director reviewed. (Activity Director)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an infection control program to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents observed for incontinence care, and 1 of 2 residents observed for a wound dressing change. Staff did not sanitize hands between glove changes, did not wear required Personal Protective Equipment (PPE), and placed a resident's open wound on bed linen. (Resident 25, Resident 3, Resident 21, Resident 27)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and a homelike environment for residents, staff, and visitors for 6 of 10 rooms observed. (Room A1, Room A4, Room B2, Room B3, Room B6, Room F2)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity when being spoken to. During 1 of 1 random interview, a resident indicated staff spoke harshly to residents during care, were short with residents, and cursed. These actions led the resident to feel angry. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for respiratory care. (Resident 32)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident that was dependent on staff for Activities of Daily Living (ADLs) received necessary care to maintain their personal hygiene for 1 of 1 resident reviewed for ADL care. A dependent resident with Moisture Associated Skin Damage (MASD) was not offered or toileted every two hours as ordered. (Resident 27)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent and treat a facility acquired pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Skin assessments were not completed and a resident's plan of care was not followed and revised to monitor and assess the resident's right ankle pressure ulcer. (Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 1 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls, a fall assessment was not completed after a fall, and an interdisciplinary note was not completed after a fall. (Resident 23)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's plan of care for nutrition was followed for 1 of 1 residents reviewed for nutrition. A resident with weight loss was not receiving the diet and supplements ordered, the resident was not being weighed weekly as ordered, and the care plan was not revised. (Resident 7)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe, secure, and orderly storage of medications in 1 of 3 medication carts observed and 1 of 2 medication storage rooms observed. (East Hall medication storage room, [NAME] Hall medication cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during 1 of 2 observations of care. Staff failed to complete hand hygiene after removal (doffing) of used gloves and prior to putting on (donning) new gloves and staff failed to complete hand hygiene immediately after doffing used gloves and prior to opening a resident's desk drawer and handing the resident a hair comb. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate care was provided to prevent and treat new pressure wounds for 2 of 3 residents reviewed for pressure wounds. Initial observations of deteriorating skin areas were not documented or communicated, initial wound care was not documented following the development of pressure wounds, and ordered treatments were not completed for pressure wounds. (Resident D, Resident F)

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist working at least part-time at that facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who did not have a gradual dose reduction for psychotropic medications had a clinical contraindication documented for 1 of 5 residents reviewed for unnecessary medications. (Resident 12)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchens observed. Hairnets did not cover hair, food temperature log was not completed for all meals, measuring devices/scoops were stored inside containers of ice, oats, sugar, thickener, and bread was touched with bare hands. (Kitchen)

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents observed for incontinence care. Staff did not use hand hygiene between glove changes during care and did not change gloves after touching multiple items before starting incontinence care. (Resident 13, Resident 27, Resident 15).

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and home-like environment for 5 of 5 halls and 1 of 1 Dining Rooms reviewed for environment. Personal items were not labeled in shared bathrooms, vent fans were caked with dust, toilets were soiled, non-skid strips were peeling up and/or worn, paint was missing, and incontinence pads were stored uncovered in the shower rooms. (A Hall, B Hall, C Hall, E Hall, F Hall, Dining Room)

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise resident's plan of care for 3 of 17 resident care plans reviewed. Care plans were not revised to reflect discontinued medications, and alarms were in use without an order or care plan. (Resident 29, Resident 1, Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practicefor 3 of 3 residents reviewed for Respiratory Care. The facility failed to obtain a Physician's Order for oxygen, failed to follow Physician Orders for oxygenation, and failed to properly store a nebulizer mouthpiece and oxygen tubing while not in use. (Resident 6, Resident 28, Resident 133)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services met the needs of each resident for 2 of 4 residents observed for medication administration and 2 of 2 residents who had medication supplies disrupted without permission. Staff obtained medications for residents from other residents supplies. (Resident 22, Resident 233, Resident 27, Resident 24)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and a secured environment was in place to prevent a resident with dementia from exiting the facility and leaving the property. On 9/3/24, after being last seen by facility staff around 2:20 P.M., a resident exited the facility and was not realized to be missing until 3:15 P.M. when a search for the resident began. The resident was located by the Activity Director approximately 200 yards off facility property along a gravel road. (Resident C) This Immediate Jeopardy began on 9/3/24 when the facility failed to ensure Resident C did not exit the facility through an unsecured door toward the back of the building, located near the facility kitchen, and either walked behind or wheeled herself off the property and approximately 200 yards along a gravel road. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide privacy and dignity for 1 of 3 residents reviewed for resident abuse. Staff members recorded video footage in resident's restroom while the resident can be identified in the background on the commode. (Resident B)

Inspectors wroteBased on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 5 of the days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 4 of 2023 (July 1, 2023 through September 30, 2023).

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate submission of all direct care staffing data into the Payroll Based Journal (PBJ) system for the reported 4th Quarter period of July 1, 2023 through September 30, 2023. Every day from July 1, 2023 through September 30, 2023 was triggered in error for licensed nursing coverage 24 hours per day due to a reporting error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure MDS (minimum data set) Assessments accurately reflected resident's status for 5 of 13 resident assessments reviewed. (Resident 1, Resident 2, Resident 4, Resident 25, Resident 10)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 2 of 2 medication carts observed and 2 of 2 medication storage rooms observed. Loose pills were observed in the medication carts, refrigerator temperature logs were not filled out completely in the medication room, and supplies were expired in the medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Food containers were not labeled, food was open to air in the refrigerator, and a food item was observed on the freezer floor. (Kitchen)

Inspectors wroteBased on interview and record review, the facility failed to ensure timely notification to the provider and family representative following a change in condition for 1 of 2 residents reviewed for nutrition, and 1 of 5 residents reviewed for unnecessary medications. The Registered Dietician and provider were not notified following a significant change in weight, and a physician was not notified after an ordered medication was not given. (Resident 22, Resident 37)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ordered therapeutic diet was provided for 1 of 2 residents reviewed for nutrition. (Resident 33)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident requiring respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for oxygen use. A resident did not receive oxygen as ordered. (Resident 20)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's clinical record was maintained with accurate documentation for 1 of 5 records reviewed for unnecessary medications. (Resident 37)

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the written contract with the Hospice provider, failed to ensure a communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for 1 of 1 residents reviewed for hospice care. The clinical record lacked documentation of ongoing communication between facility staff and hospice staff. (Resident 14)