Inspection Reports for Poplar Springs Nursing Center

The facility was found deficient in multiple areas including failure to respect resident privacy by posting personal care instructions on a resident's door, inaccurate Minimum Data Set (MDS) assessments and incomplete care plans regarding a resident's blindness, a significant medication error involving incorrect transcription and administration of Lasix, improper food storage and handling in the kitchen, and inadequate infection prevention practices related to linen handling.

The facility met all emergency preparedness requirements with no deficiencies cited. However, a deficiency was found in the smoke barrier construction where unsealed holes around data cables and electrical piping compromised the half-hour fire resistance rating in two of six smoke compartments.

The facility failed to provide the required half-hour fire resistance rating in the smoke barrier wall, affecting two of six smoke compartments. Unsealed holes around data cables and electrical piping near the A/B Nurses Station compromised the smoke barrier's ability to resist smoke passage.

The complaint investigation was substantiated by interviews and record review showing CNA #1 was rude, delayed assistance for about two hours, and made dismissive comments to Resident #1. The facility self-reported the incident, suspended, and terminated CNA #1. However, the investigation failed to include interviews of other residents who might have been affected.

The facility failed to ensure Resident #1's right to be treated with respect and dignity, as CNA #1 used inappropriate tone and language and delayed assistance. The facility also failed to thoroughly investigate the allegation by not interviewing other cognitively intact residents who received care from CNA #1 to determine if a pattern of abuse or neglect existed. CNA #1 was suspended and terminated following the investigation.

Two complaint investigations were conducted: CI MS #28191 for physical environment with no deficiencies found, and CI MS #28280 for resident rights, abuse, and neglect where a Level II deficiency was cited related to verbal abuse and neglect by a CNA towards Resident #1.

The facility was found non-compliant with resident rights due to an incident where a Certified Nursing Assistant (CNA) used inappropriate tone and language, delayed assistance to a resident, and was subsequently terminated. The resident was assessed and found to have no psychological harm. The facility provided in-services on abuse, neglect, and resident rights to staff and implemented monitoring to ensure compliance.

Two complaint investigations were conducted: MS #28191 for physical environment with no deficiencies found, and MS #28280 for abuse, neglect, and resident rights where deficiencies F550 and F610 were cited. Resident #1 alleged verbal abuse and neglect by CNA #1 on 3/14/2025. The facility terminated CNA #1 and provided in-services on abuse and neglect. The investigation failed to include interviews of other residents who may have been affected.

The facility was found non-compliant with Medicare and Medicaid participation requirements. No deficiencies were found related to the physical environment complaint. Deficiencies were cited for failure to ensure resident rights and failure to thoroughly investigate an abuse allegation involving a Certified Nursing Assistant (CNA #1) who used inappropriate language and delayed assistance to Resident #1, resulting in verbal abuse and neglect.

The facility was found not in compliance with multiple regulatory requirements including safe and homelike environment, comprehensive care planning, bowel/bladder care, respiratory care, medication administration, and infection prevention and control.

The facility was found not in compliance with several standards including urinary incontinence care, respiratory care, floor safety, and infection control. Deficiencies included inadequate perineal care leading to risk of infection, failure to date oxygen tubing, broken floor tiles posing safety hazards, and improper hand hygiene practices by staff.

The facility was found deficient in multiple areas including unsafe environmental conditions due to broken floor tiles, incomplete care plans for resident behaviors, inadequate perineal care leading to infection risk, failure to date oxygen tubing for respiratory care, medication errors involving crushing extended-release medications, and improper hand hygiene practices increasing infection risk.

The facility failed to protect corridors as required by NFPA 101 Section 19.3.6.1.1, with corridor walls and doors incapable of resisting the passage of smoke. This deficiency affected 11 of the 86 residents present during the survey.

Complaint Investigation MS #25651 was substantiated related to pharmaceutical services, neglect, and misappropriation of property.

The facility failed to provide all physician-prescribed medications to a resident who went out on therapeutic leave, resulting in noncompliance with Medicare and Medicaid participation requirements.

The complaint was substantiated as the facility failed to send Resident #1 with all active medications during therapeutic leave, confirmed by interviews with the resident's daughter, Director of Nursing, and Licensed Practical Nurse.

The facility failed to provide all prescribed medications to Resident #1 during therapeutic leave, including Aspirin, Basaglar Kwik Pen, Fiasp Injection insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. This oversight was confirmed by staff interviews and record reviews and was identified as a potential risk for adverse outcomes.

The complaint investigation (CI MS #24629) was substantiated as the facility confirmed drug diversion by LPN #1 who signed out narcotics multiple times without a prescription and tested positive for opioids and morphine. The resident tested negative for opioids. The facility took corrective actions prior to the survey date.

The facility failed to protect a resident from misappropriation of a controlled medication by a Licensed Practical Nurse (LPN #1) who tested positive for opioids and morphine without a prescription and was terminated. The facility conducted an immediate investigation, narcotic audits, staff training, and reported the incident to appropriate authorities.

The complaint investigation (MS #24629) was substantiated. The facility was found non-compliant due to drug diversion by LPN #1 who signed out medication multiple times without a prescription and tested positive for opioids and morphine. The resident tested negative for opioids. The facility reported the incident to the State Agency, Attorney General Office, State Board of Nursing, and Board of Pharmacy.

The facility failed to protect a resident from misappropriation of a controlled medication by a licensed practical nurse who diverted Norco medication intended for Resident #1. The nurse tested positive for opioids without a prescription and was terminated. The facility conducted an immediate investigation, reported the incident to relevant authorities, and implemented corrective actions to achieve compliance by 3/26/24.

The complaint investigation was substantiated. LPN #1 tested positive for opioids and morphine without a prescription, while Resident #1 tested negative for opioids. LPN #1 was terminated and the incident was reported to the State Agency, Attorney General Office, State Board of Nursing, and Board of Pharmacy.

The facility failed to protect a resident from misappropriation of a controlled medication by a licensed practical nurse (LPN #1) who signed out medication multiple times without a prescription and tested positive for opioids, while the resident tested negative. The LPN was terminated, and the incident was reported to relevant authorities. The facility conducted a full investigation, audit, and training to address the issue.

The facility failed to report complete COVID-19 information to the NHSN during a required seven-day reporting period between 08/21/2023 and 08/27/2023, which has the potential to cause more than minimal harm to residents.

The facility was found deficient in several areas including failure to provide privacy covers for urinary catheter drainage bags, failure to provide storage bags for oxygen cannulas and nebulizer masks for residents receiving respiratory treatment, and failure to ensure staff properly wore face masks and performed hand hygiene to prevent infection spread.

The facility was found not in compliance with residents' rights and special needs care requirements. Specifically, the facility failed to provide privacy covers for urinary catheter drainage bags for one resident and failed to provide storage bags for oxygen cannulas and nebulizer masks for three residents receiving respiratory treatment.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident rights, respiratory care, and infection prevention and control. Specific issues included failure to provide privacy covers for catheter drainage bags, improper storage of respiratory equipment, and staff not properly wearing face masks or performing hand hygiene.

The facility failed to provide 20-minute fire resistance rating smoke barrier doors as required by NFPA 101, affecting two of five smoke compartments and 28 of 80 residents. The A & B Hall smoke barrier doors did not close to a positive latching position and were incapable of resisting smoke passage.

The complaint investigation MS #18529 was substantiated for abuse. The physical abuse incident occurred on 2022-02-13 involving Licensed Practical Nurse #1 and Resident #1. The facility reported the incident to local police, Medicaid Fraud Control Unit, Resident's Representative, and Department of Health. Both involved employees were terminated.

The facility was found not in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The investigation substantiated abuse against one resident, Resident #1, involving physical abuse by Licensed Practical Nurse #1. Both the LPN and a Certified Nursing Assistant who witnessed but did not report the incident were terminated. The facility implemented multiple in-services and corrective actions to prevent recurrence.

The complaint investigation MS #18529 was substantiated for abuse involving Resident #1. The investigation confirmed physical abuse by Licensed Practical Nurse #1 on 2/13/22, witnessed by Certified Nursing Assistant #1 who failed to report it. Both employees were terminated. The resident had moderate cognitive impairment and no physical injuries from the incident.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to substantiated abuse involving one resident. Licensed Practical Nurse #1 physically abused Resident #1, and Certified Nursing Assistant #1 failed to report the incident. Both employees were terminated.

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period between 11/30/2020 and 12/06/2020, which has the potential to cause more than minimal harm to residents.

The complaint investigation substantiated abuse and neglect involving Residents #1, #2, and #3. Allegations included physical abuse such as slapping and verbal abuse including threats and intimidation by two Certified Nursing Assistants (CNAs). The facility reported the incidents to the Mississippi State Department of Health, Sheriff’s Department, Medicaid Fraud Criminal Unit, and Attorney General’s Office. Investigations were conducted, and employees involved were terminated.

The facility was found not in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm, substantiating abuse and neglect involving three residents. Multiple employees were found to have verbally and physically abused residents, including slapping, verbal threats, and withholding food. The facility took immediate action by placing the employees on administrative leave, notifying authorities, and conducting in-services on abuse and neglect.

The complaint investigation substantiated abuse and neglect involving Residents #1, #2, and #3. The facility failed to prevent abuse by two CNAs and failed to report the abuse within the required timeframe. The allegations included physical abuse (slapping, hitting), verbal abuse (threats, harsh language), and neglect (removal of food tray, call light). The facility self-reported the incidents and terminated the employees involved.

The facility was found not in compliance with Medicare and Medicaid participation requirements, substantiating abuse and neglect allegations involving three residents. The investigation revealed verbal, physical abuse and neglect by two CNAs towards Residents #1, #2, and #3, with failure to report the incidents timely to appropriate agencies.

The facility was found not in compliance with several requirements including resident rights, notice requirements before transfer/discharge, accuracy of assessments, development and implementation of comprehensive care plans, and activities meeting resident interests and needs. Specific issues included failure to ensure resident privacy, failure to provide written transfer notifications, inaccurate mental illness status on assessments, missing care plans for certain residents, and inadequate activity programming.

The facility was found not in compliance with resident rights and activity program requirements. Resident #59's right to privacy was violated when toileting, and the facility failed to provide activities meeting the preferences and needs of Residents #6 and #47 over multiple days.

The facility was found not in compliance due to failure to limit the use of PRN psychotropic medications to 14 days for two residents. No life safety code deficiencies or emergency preparedness deficiencies were cited.