Poplar Care Strategies

In the surveyor’s words

From the most serious findings on record at Poplar Care Strategies, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 12, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF882Nov 1, 2024

  Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist working at least part-time at that facility. Finding includes: On 10/28/24 9:45 A.M., the Director of Nursing (DON) indicated she was the facility's appointed Infection Preventionist (IP) and full time DON. On 4/5/24 at 10:08 A.M., the DON indicated she it varied from week to week on how many hours were spent for IP duties, but she does not spend as much time on IP duties as she would like to. At that time, she indicated she did not have any documentation of hours worked as an IP. […]

• No harm, potential for more than minimal, widespreadF727Jan 8, 2024

  Based 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). Finding includes: On 1/4/24 at 4:45 P.M., the [NAME] report was reviewed and indicated there was not an RN for 8 consecutive hours on the following dates: 7/3/23 8/5/23 8/6/23 8/18/23 8/27/23 9/10/23 9/16/23 9/17/23 9/21/23 9/23/23 9/24/23 9/30/23 On 1/3/24 at 9:15 A.M., the Time Card Report from 7/1/23 through 9/30/23 was provided by the Administrator. Review of the Time Card Report indicated there was no RN coverage for 7/3/23, 8/27/23, 9/10/23, 9/23/23 and 9/24/23. […]

• No harm, potential for more than minimal, widespreadF851Jan 8, 2024

  Based 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. Finding includes: On 1/3/24 at 8:15 A.M., review of the facility's PBJ information indicated licensed nursing coverage for 24 hours per day was triggered daily in the 4th reporting quarter of July 1, 2023 through September 30, 2023. […]

• No harm, potential for more than minimal, patternF583Jan 8, 2026

  Based 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)Findings include:1. On 1/6/26 at 3:19 A.M., Licensed Practical Nurse (LPN) 17 and Certified Nurse Aide (CNA) 18 were observed to enter Resident 21's room without knocking. Resident 21 was in the room at that time. 2. On 1/5/26 at 10:09 A.M., Certified Nurse Aide (CNA) 25 was observed to enter Resident 21's room without knocking. Resident 21 was in the room at the time. On 1/7/26 at 9:23 A.M., Registered Nurse (RN) 21 was observed to enter Resident 21's room without knocking. […]