The Green House Cottages of Poplar Grove

Inspectors wroteBased on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure care planned fall interventions were implemented for one (Resident #1) of three residents reviewed for quality of care. It was also determined that the facility failed to notify Resident #1's guardian that the resident refused to take ordered medication more than two times in a row.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure the rear casters of the mechanical lift were not locked with lifting and lowering resident to prevent accidents and injuries affecting 1 sampled (Resident #270) of 4 sampled residents reviewed for accidents. The facility failed to ensure the residents environment was free of accidents and hazards for 1 sampled (Resident #48) of 4 sampled residents reviewed for accidents and hazards.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that pills were properly stored in the acceptable package or bottle to prevent mediation errors in Building 1 and failed to ensure a thermometer and temperatures were being monitored in the narcotic refrigerator in Building 4 to ensure medications were stored at an appropriate temperature.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure that a comprehensive care plan addressed pain for 1 of 1 sampled resident (Resident #58) reviewed for pain management to ensure appropriate interventions were in place.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #2) of 2 sampled residents that were reviewed for respiratory therapy.

Inspectors wroteBased on observation and facility policy review, the facility failed to ensure expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria, and to ensure food stored in the freezer were appropriately dated.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed appropriately with peri care to prevent cross contamination, and the spread of infection. This failed practice affected 1 sampled (Resident #270) resident requiring assistance for incontinence care, with the potential to affect 2 sampled (Resident #58, Resident #270) residents reviewed for bowel and bladder.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain an orderly, uncluttered environment for 1 (Resident #3) of 3 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff washed their hands when serving meals, follow the menu and ensure the menu was posted.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fingernails were regularly trimmed to maintain good hygiene and grooming for 1 Resident #4 sampled residents who required staff assistance with nail care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; 5 of 10 ice machines and 7 of 10 ice scoop holders were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 10 of 10 kitchens; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed; glucometers were cleaned before and after each use; hand hygiene was performed between residents; medication cart was not left unlocked and with medications on top, and the computer screen was closed when out of the line of sight of the nurse. during medication pass.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services to maintain grooming, personal hygiene, and nail care for 1 (Residents #310) of 1 sampled residents who required assistance for nail care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident centered activities program was provided daily in each cottage.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than 5% during the medication pass.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed to prevent significant medication errors for 2 (Residents #80 and #106) of 2 sampled residents observed during medication pass.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were removed from the medication storage rooms and medication carts.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu and facility quantified recipe for super calorie was followed to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who received meals in Cottage #3, 2 residents who received pureed diets and 2 residents who received super calorie foods in Cottage #10.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance and nutritive value of pureed foods that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 2 residents who receive meal trays in the Cottage #10, as documented on a list provided by Dietary Supervisor on 10/17/23 at 10:58 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets as provided by the Dietary Supervisor on 10/16/23 at 10:58 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lids on 2 of 2 garbage dumpsters were closed and contained to decrease the potential for pest infestation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-use glucometer was disinfected after each resident for 2 (Residents #106 and #312) and failed to ensure staff performed hand hygiene during the administration of medication for 4 (Residents #67, #80, #106 and #312) sampled residents who were observed during medication pass.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed to address diabetic fingernail care for 1 (Resident #310) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure an elopement was immediately reported to the state agency for 1 (Residents #1) of 1 case mix resident who had eloped from the facility.