Poplar Springs Nursing Ctr, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to dignity and privacy by posting personal care instructions on the exterior of a resident's door for one (1) of 21 sampled residents, Resident #54.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's vision status for one (1) of 21 sampled residents. Resident #8.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan that addressed a resident's visual impairment for one (1) of 21 sampled residents. Resident #8.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident received the necessary care and services by not identifying, assessing, or addressing his visual impairment for one (1) of 21 sampled residents, Resident #8.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident was free from a significant medication error when a nurse incorrectly transcribed and administered Lasix (a diuretic) at a higher dose than prescribed for one (1) of 21 sampled residents, Resident #2.

Inspectors wroteBased on observation and staff interview, the facility failed to store food and maintain food quality in accordance with professional standards for food safety related to overly ripe produce and exposed spice products for one (1) of two (2) kitchen observations. On July 21, 2025, at 10:15 AM, an initial observation and interview with the Kitchen Supervisor revealed refrigerator #1 contained 11 tomatoes exhibiting white biological growth. The spice rack in the food preparation area revealed three bottles of dry seasonings with their lids open, leaving the seasonings exposed. The Kitchen Supervisor acknowledged the presence of overly ripe produce and the opened spice bottles. The Kitchen Supervisor stated that she is responsible for maintaining safety and quality standards in the kitchen and that the staff receive regular in-service training on food safety. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection by not properly covering clean linens during transport and by placing clean linens against worn clothing for one (1) of two (2) laundry observations. A review of the facility's policy, Infection Prevention and Control Program, dated 8/2017, revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines.10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be treated with respect and dignity for one (1) of three (3) residents reviewed for resident rights, Resident #1, when a Certified Nursing Assistant (CNA) used an inappropriate tone and language when responding to the resident's request for care and failed to provide timely assistance, resulting in the resident feeling dismissed and disrespected.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, the facility failed to interview other cognitively intact residents who received care from the alleged perpetrator (CNA #1) to determine whether a pattern of verbal abuse or neglect existed.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in a manner to prevent the possibility of complications as evidenced by oxygen tubing that was not dated to indicate weekly oxygen tubing/nasal cannula changes for one (1) of one (1) resident reviewed for respiratory care. Resident #18. Findings Include: A review of the facility's Nebulizer and Oxygen Tubing Storage Policy, dated 4/2007, revealed, .It is the policy of the facility to reduce the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respirator equipment. Procedure .The facility will replace all respiratory tubings weekly. [...]

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure hands were cleaned with soap or hand sanitizer before, during, and after providing perineal care for one (1) of two (2) residents observed for catheter/perineal care. (Resident #69) Findings Include: A review of the facility's Hand Sanitizing Procedure, revised 4/2015, revealed: .It is the policy of this facility to use hand sanitizer .between handwashing when hands are not visibly soiled or dirty. Procedure .use an alcohol-based hand rub .for all the following situations: 1. Before and after direct contact with residents .10. After removing gloves. A review of the facility's Procedure for Handwashing, revised 4/2015, revealed, .2. Apply one squirt of soap . [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure the resident's rights for a safe and homelike environment as evidenced by broken floor tiles in two areas of the hallway for one (1) of eight (8) hallways observed. (Therapy room hallway). Findings Include: A review of the facility policy titled Safe and Homelike Environment, undated, revealed, .In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment . This includes ensuring that the resident can receive care and services safely, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . On 8/27/24 at 9:07 AM, during an observation, there were several broken floor tiles in the hallway in front of an exit door. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to develop care plan interventions related to a resident's behaviors for one (1) of 18 care plans reviewed. (Resident #75)

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure perineal care was provided in a manner to prevent complications for one (1) of two (2) residents reviewed for care catheter/bowel and bladder care. (Resident #83) Findings Include: A review of the facility's Perineal Care Policy, revised 1/2010, revealed: .It is the policy of this facility to provide perineal cleanliness and comfort to the resident, to prevent infections and skin irritation, and observe the resident's skin condition .Procedure .For a male resident .b. Wash perineal area starting with urethra and working outward .(3) Continue to wash the perineal area including the penis, scrotum, and inner thighs . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (5%) as evidenced by four (4) errors were observed out of 39 medication administration opportunities. This affected one (1) of three (3) residents observed during medication pass, resulting in a medication error rate of 10.26%. (Resident #27) Findings Include: A review of the facility's policy, Medication Administration, dated 09/01/2022, revealed: Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .11 .c. Crush medications as ordered. Do not crush medications with do not crush instructions .Example Guidelines for Medication Administration .Do Not Crush Medications: Slow release, enteric coated . [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide services in an acceptable standard of practice as evidenced by, a resident who went out on therapeutic leave was not provided with all physician prescribed medications for one (1) of four (4) residents sampled. Resident #1. Findings Include: On 7/16/2024 at 9:35 AM, in an interview with Resident #1's daughter, she stated her mother was sent home on therapeutic leave without medications that were needed for the continuation of care. She confirmed the medications the facility failed to send with her mother while she was on leave included Aspirin, Basaglar Kwik Pen (insulin), Fiasp Injection insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. Resident #1's daughter stated the therapeutic leave had been planned well in advance and she was taking her mother out of the state for a week. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of a controlled medication for one (1) of three (3) sampled residents. Findings Include: A review of the facility's policy titled, 7 Types of Abuse, dated 10/2016 revealed, . 7. 'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .Taking Their Medications . Record review of the facility investigation Allegations of Abuse/Misappropriation of Pain Medication dated 3/25/24, revealed Resident #1 had been receiving Norco 10-325 milligrams (MG) between two to three times on most days. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide a privacy cover for a urinary catheter drainage bag for (1) of 20 sampled residents. Resident #80.

Inspectors wroteBased on observation, staff, resident and resident representative interview, record review and facility policy review the facility failed to provide storage bags for oxygen cannulas and nebulizer masks for three (3) of 23 residents receiving respiratory treatment.

Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to prevent the possible spread of infection as evidenced by staff not properly wearing face masks, covering the nose and mouth and not performing hand hygiene between each meal tray passed and tray set up for one (1) of four (4) days of survey. Findings Include: Review of the facility's policy, Hand Sanitizing Procedure, revised 06/2018, revealed, .It is the policy of this facility to use hand sanitizer .as a substitute between hand washing when hands are not visibly soiled or dirty. Hand sanitizer will be used between each meal tray passed and tray set up . Review of the facility's policy, Interim COVID-19 Visitation Policy, revised 09/22, revealed, .Policy Explanation and Guidelines .4. The core principles of COVID-19 infection prevention will be adhered to as follows . f. [...]