Inspection Reports for
Edgewood Spring Creek Eagle Island

.305.02.b. Current Medication Orders and Treatment Orders: the facility did not ensure residents received medications as ordered; Resident #4 missed multiple doses of Biothroid, Vitamin D3, Zinc, and other medications between March and April 2024 as medications were sent out for bubble packing or awaiting orders.

.320.08. Periodic Review: Resident #4's negotiated service agreement was not updated to reflect current needs, missing wound care instructions and accurate assistance levels, despite the facility nurse acknowledging the need for updates.

.009.03.b. Availability to Work: the facility had not obtained completed criminal history background check results for three staff members, who had not consistently worked in line of sight of a cleared employee; two were observed working alone with residents, and the administrator was unaware of these issues.

.215.08.d. Written Response to Complaint within Thirty Days: the administrator did not provide written responses to complaints about sexual abuse and missing food, stating unawareness of the requirement despite investigating the issues.

.330.09. Resident Admission and Discharge Register: the facility did not maintain an up-to-date admission and discharge register, with multiple residents not listed on either electronic or handwritten versions.

.330.13. Personnel Records: all ten staff records reviewed lacked required documentation including orientation, training, medication certification, continuing education, and CPR/first aid certifications (previously cited 5/12/22).

.645.02. Delegation: a new facility nurse had not delegated medication administration and nursing tasks to staff, leaving many staff members without delegation and unsure of procedures for resident care.

.215.01 Administrator Responsibility: the facility did not ensure policies and procedures were implemented to fulfill requirements for abuse prevention and reporting. Multiple allegations of abuse of residents were not reported to Adult Protection, and protective measures were not implemented after incidents, including failure to suspend alleged abusers and provide 1:1 supervision (previously cited 03/10/2023).

.215.07 Notification to Adult Protection and Law Enforcement: four separate allegations of abuse were not immediately reported to Adult Protection. Staff were not instructed to notify Adult Protection when witnessing abuse, and the administrator did not notify Adult Protection because he did not believe the abuse occurred.

.215.08.a Administrator Notification: allegations of abuse of residents were not immediately reported to the administrator as required.

.215.08.b Investigation within Thirty Days: the administrator did not conduct thorough investigations into abuse allegations, only interviewing alleged abusers and witnesses, and failed to interview other staff or investigate injuries of unknown origin.

.215.08.c Resident Protection: alleged abusers continued to work with residents without immediate suspension or adequate protective measures such as 1:1 supervision after abuse incidents.

.215.08.e Corrective Action: the facility did not implement corrective actions to prevent recurrence of incidents, including falls and injuries of unknown origin, or abuse incidents (previously cited 03/10/2023).

.215.08.f Notification to Licensing Agency within One Business Day: the administrator failed to report significant bruising, injuries of unknown origin, and elopement incidents to Licensing and Certification.

.305.03 Resident Health Status: nursing assessments were not conducted when residents experienced changes in physical or mental health status, including after bruising, falls, elopement, and signs of infection (previously cited 03/10/2023).

.330.04.c.xi Resident Care Records: the facility did not consistently document unusual incidents or accidents in residents' records, including abuse allegations and investigations, with documentation kept separate from resident records.

.330.06.b Behavior Documentation: the facility did not develop or implement behavior plans with specific interventions for residents exhibiting maladaptive behaviors, including elopement and sexually inappropriate behavior (previously cited 05/12/2022).

.510 Requirements to Protect Residents from Abuse: the facility failed to protect residents from abuse by not immediately notifying Adult Protective Services, not completing thorough investigations, and not protecting residents after abuse allegations. Staff were not instructed to report abuse to APS, and the administrator made judgment calls not to report. Multiple staff reported concerns about rough handling and abuse that were not addressed. Specific incidents of physical and sexual abuse were inadequately investigated and managed, with failure to implement protective measures such as 1:1 supervision.

.215.08.d. Written Response to Complaint within Thirty Days: the administrator was unable to provide a complaint log with written responses and did not document responses to verbal complaints from residents or family members.

.305.03. Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including multiple falls, a laceration, urinary tract infection, and COVID-19 diagnosis.

.305.04. Recommendations: the facility nurse did not consistently make recommendations to medical providers, outside agency staff, or families regarding residents’ health needs requiring follow-up care or evaluation, with family decisions overriding further evaluation.

.215.08.e. Corrective Action: the facility did not have interventions for incidents and accidents to prevent recurrences, including multiple falls experienced by residents without developed or implemented interventions.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documentation for testing of installed Alcohol-Based Hand Rub dispensers each time a refill is replaced, no documentation for staff training review on Emergency Action Plan roles bi-monthly, and no documentation for residents' training on Emergency Action Plan roles (repeat).

.405.02.a. Prohibited applications: relocatable power taps were used with medical equipment in rooms 209A and B to supply power to oxygen concentrators.

.405.02.b. Prohibited applications: relocatable power taps were daisy-chained in the IT closet.

.405.02.c. Prohibited applications: relocatable power taps were used with appliances, including a mini-fridge in room 209A and curling irons and hair dryers in the beauty salon.

.405.03. Medical gases: no policy and procedure for elimination of sources of ignition or misuse of flammable substances in accordance with NFPA 99, Chapter 11, Section 11.5.

.410. Requirements for emergency actions and fire drills: evacuation drills did not document evacuation to any of the three listed points of assembly in the Emergency Action Plan.

.009.01 Criminal history and background check: two of seven employees did not have a Department criminal history and background check completed.

.310.01.c Medication distribution system: medication refrigerator temperatures were not maintained in the correct range, with multiple instances of out-of-range and unrecorded temperatures documented.

.330.06.b Behavior documentation: the facility did not develop behavior plans and interventions for residents exhibiting behaviors, including physical aggression and lack of personal hygiene (previously cited 11/20/2018).

.330.13.f Personnel records: two of seven employees did not have documentation of current CPR or first aid certification despite training being provided.

.305.02.b. Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents received their medications as ordered, including missed doses of Lantus and hydrocodone-acetaminophen due to miscommunication and medication shortages (previously cited 12/12/2019).

.305.03. Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including a swollen lip, a fall, and unknown bruising that were not assessed (previously cited 12/12/2019).

.645.02. Delegation: four of fifteen staff who passed medications were not delegated by the facility nurse, confirmed by the administrator and facility nurse.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documentation for testing of Alcohol Based Hand Rub dispensers each time a refill is replaced, and no documented sensitivity testing completed for addressable fire alarm system since new construction in 2015 (repeat).

.405.03 Medical gases: one unsecured oxygen cylinder in medication room of memory care; all cylinders must be secured by a rack or chained (corrected on site 7/12/2021).

.405.01.b Electrical installations and equipment: extension cords and multiple plug adapters are prohibited; Room 216 was using a 3-1 non-grounded extension cord and a second extension cord to supply power to appliances in the room.

.405.05 Structure, maintenance, equipment to assure safety: no record for 90-minute emergency lighting testing in the past twelve months; emergency lighting circuit boards may be part of a 2014 fire-hazard recall with 37 of 41 e-lights not replaced or examined; no record of four-year testing on fire dampers in HVAC system; suspended ceiling in Utility Room inside Memory Care unit had missing ceiling tiles and an open fire door allowing fire and smoke to bypass suppression systems.

.161.03.e Policy content: smoking was conducted on terrace outside room 216, a non-designated smoking area, with combustible paper trash intermixed with cigarette butts and ashes; no metal trash can with self-closing lid was present.

.410.02 Fire drills: no documentation of night shift fire drill for second quarter of 2019.

.405.05.f Structure, maintenance, equipment to assure safety: Life Enrichment Director was using a portable heater in the office.

.415.04.a Fire alarm smoke detection system service and testing: fire alarm system report showed elevator devices were not inspected and audible/visible notification device in room 113 had failed with no record of repair; no record of sensitivity testing since fire alarm system installation in 2015.

.215.10 Notification of Reportable Incidents: the facility administrator did not notify Licensing and Certification for incidents where Resident #5 fell and required sutures and hospitalization, and Resident #8 had a fall with injury requiring sutures.

.300.01 Licensed Professional Nurse (RN): the facility nurse did not conduct change of condition nursing assessments on 3 of 10 sampled residents, including incidents involving Resident #1, Resident #2, and Resident #4 (previously cited 12/7/2017).

.305.02.b Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents had medications available as ordered, including missing Alprazolam for Resident #1, morphine sulfate for Resident #2, Fluticasone for Resident #4, and Loratidine and Acetaminophen for Resident #7.

.320.01 Use of Negotiated Service Agreement: NSA's were not updated to reflect residents' specific needs, such as increased care needs for Resident #6, missing mobility/transfer instructions for Resident #5, undocumented mobility status change for Resident #2, and lack of hospice care details for Resident #3.

.215.08 Procedures for investigations: the administrator did not ensure facility procedures were implemented when investigations were not conducted for resident altercations and incidents involving residents left unsupervised or in the parking lot (previously cited 11/20/2018).

.330.02 Resident record retention: the facility was unable to provide February 2019 ADL records for 5 of 7 sampled residents and 25 other residents on the second floor, with staff unable to locate the records.

.711.08.e Care notes: the facility did not document all unusual or significant events, including incidents where eight or nine residents were left unsupervised in the facility van and an unidentified resident was in the parking lot without staff knowledge (previously cited 11/20/2018).

.159.01 Complete and Accurate Records: the facility did not ensure residents' records were accurately maintained; family contact was falsely documented and caregiver statements were unsigned and inconsistent.

.215.08 Procedures for Investigations: the administrator failed to implement policies to investigate and report allegations of abuse and neglect, including an incident where a resident was forcibly removed from the kitchen area.

.225.01 Evaluation for Behavior Management: the facility did not evaluate behavioral symptoms of residents to develop management plans despite documented resistive and combative behaviors.

.225.02 Intervention: the facility did not develop interventions for residents' behaviors as required.

.350.04 Written Response to Complaint Within Thirty Days: the administrator did not provide a written response to a family who raised concerns about staff compassion.

.350.06 Corrective Action for Known Allegations: the administrator did not protect residents when abuse and neglect allegations were reported, including caregivers neglecting duties and threatening residents.

.711.01 Ongoing Resident Care Records: the facility failed to document times, dates, interventions, and effectiveness related to residents' behaviors.

.711.08.c Care Notes: the facility did not document all unusual or significant events such as resident altercations and changes in condition.

.711.08.e Care Notes: caregiver communications with the facility nurse via text messaging were not included in residents' records.

.130.04 Access and Authority to Entire Facility: the facility denied State Surveyors immediate and full access to residents' records by withholding caregiver documentation for over 30 hours and instructing staff to deny its existence.

.525 Requirements to Protect Residents from Neglect: see related abuse citations as the facility was cited for both abuse and neglect.

.510 Requirements To Protect Residents From Abuse: the facility failed to protect residents from abuse and neglect, did not report to Adult Protection, and failed to investigate allegations despite multiple staff and family reports of mistreatment and neglect affecting multiple residents.

.405.01 Medical Gases: blocked electrical panels in mechanical and electrical room off of the garage (NFPA 70.110.26).

.405.01.b Electrical Installations and Equipment: full sized dryer plugged into a relocatable power tap used as a substitute for fixed wiring in the memory care laundry (NFPA 70, 400.8).

.405.03 Medical Gases: four unsecured oxygen tanks in the memory care storage room off of the shower room and one unsecured oxygen tank in the second floor nurses station (NFPA 99, 4-3.1.1.1).

.405.05 Structure, Maintenance, Equipment to Assure Safety: no documentation for the 30 second monthly testing of the emergency lighting from November 2017 to present and non-operational emergency lighting in multiple areas including main floor front entry, hallways outside hair salon and memory care, and second floor near activity room and snack area (NFPA 101, 7.9).

.300.01 Licensed Professional Nurse (RN): there was no documentation a quarterly nursing assessment was completed for Resident #6 in May 2017; Resident #2's quarterly nursing assessment was completed by the LPN and not reviewed or signed by the RN; Resident #3's admission assessment was completed by the LPN and not reviewed and signed by the RN; missing change of condition assessments for Resident #3 and Resident #5's wounds.

.711.08 Care Notes: signed and dated care notes by direct care staff were not maintained in the ongoing residents care records; notes were written on a white board and texts were sent to the facility nurses regarding residents changes in condition such as falls (previously cited 7/11/2016).

.520-11 Inadequate Care - Acceptable Admission and Retention: the facility admitted and retained Resident #3 who had a pressure ulcer greater than a Stage II; the wound was unstageable due to eschar and was not documented or assessed on admission; Resident #3 was retained for 141 days with an unstageable left heel pressure ulcer resulting in inadequate care.

.009.01 Criminal history and background check: a housekeeper did not have evidence of a completed criminal history and background check.

.009.06.c Use of previous criminal history and background check: one of three employees did not have evidence of a state police background check.

.310.04.a Psychotropic or behavior modifying medication: the facility did not document non-drug interventions prior to requesting behavior modifying medications. Medications were given to Resident #7 for agitation, but no interventions were documented. Risperidone was given to Resident #1 for wandering at night and agitation.

.330.03 Resident record confidentiality: the facility did not safeguard resident information when they wrote resident information on a dry-erase board and did not ensure that information was documented in the residents' records. Also, the facility did not protect residents' information when the ADL book was left out in the open.

.711.08 Care notes: the facility did not ensure care notes were signed and dated by the person providing the care and services and did not ensure this information was included in the resident's record.