Colonial Poplin Nursing Home

In the surveyor’s words

From the most serious findings on record at Colonial Poplin Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based on interview and record review, the facility failed to have a water management plan that included all the necessary elements to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 42 residents.Findings include:Review on 4/30/26 of the facility's Water Management Plan, revised on 2/23/26, revealed the plan did not include an accurate description of the facility water system, did not identify specific areas where Legionella could grow and spread, and did not establish ways to intervene when identified control limits were not met. […]

• No harm, potential for more than minimal, patternF658Jul 15, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to follow or clarify physcian orders for 4 residents in a final sample of in a final sample of 16 residents (Resident identifiers are #17, #100, #12, and #3). Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #17 Interview on 7/13/22 at 11:12 a.m. […]

• No harm, potential for more than minimal, patternF727Jul 15, 2022

  Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day, 7 days a week for 6 out of 14 weekend days reviewed. Findings include: Interview on 7/13/22 at 8:51 a.m. with Staff A (Administrator) revealed that the facility did not have any nurse staffing waivers. Review on of the facility's daily staffing from 6/4/22 to 7/15/22 revealed that a Registered Nurse was not scheduled or documented as worked on Saturday and Sunday for the following days: 6/11/22, 6/12/22, 6/25/22, 6/26/22, 7/9/22, 7/10/22 (total of 6 days). Interview on 7/15/22 at 2:40 p.m. with Staff A (Administrator) confirmed that there was not a Registered Nurse on duty the above dates.

• No harm, potential for more than minimal, patternF658Jun 30, 2021

  Based on observation, interview, and record review it was determined that the facility failed to ensure that services met professional standards according to accepted standards of clinical practice for 1 of 4 residents reviewed for pain management, following physicians orders for 1 out of 11 residents reviewed, and clarifying physicians orders for 2 out of 11 residents reviewed in a final sample of 11 residents. (Resident identifiers are #24, #38, #41 and #140.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. […]

• No harm, potential for more than minimal, isolatedF880May 1, 2024

  Based on observation, interview, and record review it was determined that the facility failed to implement their policy and procedures for Transmission Based Precautions (TBP) for 3 of 4 residents reviewed for infection control practices for COVID-19 (Resident Identifiers #4, #36, and #38). Findings include: Review on 5/1/24 of the facility's COVID-19 Positive Tracking report revealed the following; Resident #4 tested positive for COVID-19 on 4/20/24 and had no symptoms. Resident #36 tested positive for COVID-19 on 4/25/24 and had no symptoms. Resident #38 tested positive for COVID-19 on 4/20/24 and was symptomatic. Observation on 4/30/24 at 10:10 a.m. of Staff A (Dietary Manger) was in Resident #4's room talking to Resident #4 within approximately 3 feet of the resident. […]