Inspection Reports for
The Green House Cottages of Poplar Grove

The complaint investigation found that Resident #1 had multiple medication refusals without proper guardian notification as requested. The guardian was notified only once before the final call on 05/07/2025 despite multiple refusals. The facility failed to research reasons for refusals or implement alternate treatments.

The facility failed to ensure fall prevention interventions were implemented for Resident #1 and did not notify the guardian when the resident refused ordered medications more than twice in a row. Observations confirmed absence of fall mats and signage. Medication refusal rates were high, and guardian notification was inconsistent.

The investigation was complaint-related, focusing on failure to implement fall interventions and failure to notify the guardian of medication refusals. The guardian was notified only sporadically despite requests for notification after each refusal.

The facility failed to implement fall prevention interventions for Resident #1 and did not notify the resident's guardian after multiple medication refusals. Observations confirmed absence of fall mats and signage in the resident's room. Medication Administration Records showed numerous refusals of prescribed medications. Interviews with staff and the guardian confirmed inconsistent notification of medication refusals.

The facility was found deficient in multiple areas including incomplete care planning for pain management, unsafe use of mechanical lifts, unsecured oxygen tanks, improper oxygen therapy administration, medication storage issues, expired food items, and inadequate infection prevention practices related to hand hygiene during peri care.

The facility was found deficient in multiple areas including failure to develop a comprehensive care plan addressing pain management, improper use and storage of mechanical lifts, unsecured oxygen tanks, incorrect oxygen flow rates, improper medication storage and temperature monitoring, expired and undated food items, and inadequate infection prevention practices related to hand hygiene during incontinence care.

The facility failed to maintain an orderly, uncluttered environment for Resident #3, with clutter and equipment in the bathroom preventing access to the shower and toilet. Resident #3 reported preferring showers but was limited to bed baths due to the clutter. Staff confirmed the bathroom was too cluttered to provide showers. The Administrator acknowledged the issue and indicated plans to remove some equipment.

The facility failed to maintain an orderly, uncluttered environment for one resident (Resident #3), whose bathroom was cluttered with multiple wheelchairs, a shower chair, and other items, limiting access to the shower and toilet. The resident reported preferring showers but was unable to use the bathroom due to clutter, and staff confirmed the clutter prevented shower access.

The complaint investigation found substantiated issues including inadequate nail care for Resident #4 and poor food service hygiene practices, such as staff not washing hands and failure to post or follow the menu.

The facility failed to ensure proper nail care for a resident requiring assistance, with nails found excessively long and jagged, and no documented refusals of care. Additionally, the facility failed to ensure staff washed hands when serving meals, followed the menu, and posted the menu as required.

The facility failed to ensure proper nail care for a resident requiring assistance, lacked a policy for ADL care, and failed to ensure staff washed hands when serving meals, followed the menu, and posted the menu as required.

The facility failed to ensure meals were prepared and served according to planned menus and recipes, maintain palatability and safe temperatures of food, ensure pureed foods were smooth and safe, and maintain sanitary conditions in food storage and preparation areas. Multiple food safety and hygiene violations were observed, including unclean ice machines, expired or undated food items, improper hand hygiene, and inadequate reheating of food.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for diabetic nail care, medication administration errors, inadequate infection control practices including improper cleaning of glucometers and hand hygiene, failure to provide resident-centered activities, improper food preparation and storage practices, and failure to maintain sanitary conditions in dietary and waste management.

The facility failed to ensure meals were prepared and served according to planned menus and recipes, maintain palatability and safe temperature of foods, ensure pureed foods were smooth and safe, and maintain proper food storage and hygiene practices. Multiple issues with food consistency, temperature, contamination risks, and sanitation of equipment were observed across several cottages.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for diabetic nail care, medication administration errors, inadequate infection control practices including failure to clean glucometers and perform hand hygiene, failure to provide resident-centered activities, improper food preparation and storage practices, and failure to maintain sanitary conditions in food service areas.

The complaint investigation was substantiated as the facility did not report the elopement of Resident #1 to the Office of Long-Term Care within 2 hours as required. The report was completed the following day, exceeding the required timeframe.

The facility failed to ensure that an elopement of Resident #1 was immediately reported to the Office of Long-Term Care within the required timeframe. The resident eloped on 9/30/23 and the report was completed the following day, not within the mandated 2-hour window.

The complaint investigation found that Resident #1 eloped from the facility on 09/30/23 at approximately 6:47 AM. The facility reported the incident to the Office of Long-Term Care on 10/01/23 at 10:30 PM, which was beyond the required 2-hour reporting window. The Director of Nursing and Administrator confirmed the delay and lack of clear policy on timely reporting.

The facility failed to ensure that an elopement of Resident #1 was immediately reported to the Office of Long-Term Care as required. The resident eloped on 09/30/23 but the report was not made within the required 2-hour timeframe.

The complaint investigation found that Residents #2 and #7 did not receive documented baths or showers during the lookback period despite care plans indicating the need for assistance. There was no documented refusal of care. The Director of Nursing was unable to clarify some documentation entries. The bathing documentation showed multiple days with no recorded baths or showers.

The facility failed to provide baths or showers to two sampled residents who required assistance, potentially affecting 20 residents dependent on bathing assistance. Documentation was incomplete or missing for bathing care during the review period.

The facility failed to provide baths or showers to two sampled residents who required assistance, potentially affecting 20 residents dependent on bathing assistance. Documentation was incomplete or missing for bathing services during the review period, and staff were uncertain about the meaning of certain documentation codes.

The facility failed to ensure medications were properly stored in a secure location, resulting in unsecured medications being left out on a dining room table accessible to residents and staff. This posed a risk of accidental ingestion or unauthorized access, particularly for one ambulatory resident.

The facility failed to ensure medications were properly stored in a secure location, resulting in unsecured medications being left out on a dining room table, posing a risk of accidental ingestion. Multiple staff members, including nurses and the Director of Nursing, acknowledged the importance of securing medications and the potential harm if left unsecured.

The facility was found deficient in multiple areas including failure to assist a resident out of bed for breakfast, incomplete care plans regarding Foley catheter and urinary tract infection history, inadequate personal hygiene care such as nail care and shaving, medication errors including missed insulin dose and expired medications, improper food storage and sanitation practices, and multiple broken kitchen and dietary equipment impacting meal preparation.

The facility was found deficient in multiple areas including failure to assist a resident out of bed for breakfast, incomplete care plans for residents with Foley catheters and urinary tract infections, inadequate personal hygiene care such as nail care and shaving, medication errors including missed insulin doses, presence of expired medications, improper food storage and handling in kitchens, and multiple pieces of dietary equipment being out of order for extended periods.