Inspection Reports for
Edgewood Spring Creek Eagle, LLC

.009.04 Submission of fingerprints: one of seven staff did not have documentation that fingerprints were submitted within 21 days of hire as required.

.310.04 Psychotropic or behavior modifying medication: the facility did not complete six-month psychotropic medication reviews for three residents taking such medications for six months or more due to a recent change in nursing staff.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility lacked documentation for a 3-year full-trip test of the dry sprinkler system, fire extinguishers were not inspected monthly in November and December 2020, staff training on oxygen use was not documented, an emergency light was non-operational, and conduit openings in the mechanical/electrical room were not sealed to prevent passage of smoke, fire, and gases.

.405.01 Electrical installations and equipment: resident room #6 had a non-grounded "zip" style extension cord in use.

.405.02.b Prohibited applications: mechanical room had a "daisy chain" on the IT wall, Relocatable Power Tap (RPT) to RPT.

.405.02.c Prohibited applications: resident room #11 had a microwave plugged into a RPT in the shared foyer.

.330.04.c.vi Resident care records: the facility did not have a system for staff to document when they contacted the facility nurse; there was no documentation in multiple residents' records of nurse notifications when medications were required or residents' conditions changed.

.600.04.a Sufficient personnel: the facility's as-worked schedule documented caregivers worked alone on the night shift; two caregivers did not have Medication Assistance Certifications and were instructed to contact the facility nurse to pass medications.

.600.04.b Sufficient personnel: two staff members who worked alone did not have CPR/first aid certification.

.250.10 Plumbing: water temperature at resident room sink was 123 degrees.

.250.13.l Resident sleeping rooms: closet door had been removed in resident room #17 with no variance for its removal on file.

.405.03 Medical gases: five unsecured oxygen cylinders in the closet of resident room 11a (corrected by Administrator 6/6/19).

.415.04.a Fire alarm smoke detection system service and testing: no documentation for a 5 year sensitivity test of the smoke detectors; maintenance supervisor verified the system is not addressable.

.009.06.c Use of Previous Criminal History and Background Check: one of seven employees who required an Idaho State Police check did not have an ISP check in their personnel file.

.310.04.e Psychotropic or Behavior Modifying Medication: behavioral updates were not sent to the physician every six months for residents that utilized psychotropic medications.

.320.01 Use of Negotiated Service Agreement: NSA's were not updated to reflect the residents specific needs, including incorrect self-administration of medication for Resident #2, no current NSA for Resident #6, and missing food preparation needs for Resident #7.

.410.02 Fire Drills: fire drills are being conducted as "Mock" silent drills on day and PM shifts and not implementing the fire protection plan; Noc/silent drills were not conducted implementing this plan.

.405.03 Medical Gases: unsecure oxygen cylinders in room #27; nurse on staff secured on site on 11/4/15.