Inspection Reports for Edgewood Spring Creek Eagle Island

The inspection was conducted as a health care complaint investigation regarding medication administration and care plan issues for Resident #4.

The facility failed to ensure Resident #4 received medications as ordered multiple times between March and April 2024, and the resident's Negotiated Service Agreement (NSA) was not updated to reflect current care needs, including wound care instructions and assistance levels.

The investigation was triggered by a complaint related to medication administration and care planning for Resident #4. Substantiation status is not stated.

The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.

The survey identified multiple deficiencies including incomplete criminal background checks for staff, failure to provide written responses to complaints, inaccurate resident admission and discharge registers, incomplete personnel records, and lack of delegation of nursing tasks by the new facility nurse.

The visit included investigation of complaints from Resident #7's family alleging sexual abuse and Resident #6 regarding missing leftovers; both complaints lacked timely written responses from the administrator.

The inspection was conducted as a health care complaint investigation to assess allegations of abuse and the facility's compliance with policies and procedures related to resident protection and incident reporting.

The facility failed to protect residents from abuse, did not immediately notify Adult Protective Services, did not conduct thorough investigations, and failed to implement adequate corrective actions and protective measures. Multiple allegations of physical and sexual abuse were substantiated involving several residents, with failures in reporting, investigation, and resident protection.

The complaint investigation focused on multiple allegations of abuse involving Residents #1, #2, #4, and #7. The allegations included physical abuse by staff members and sexual abuse by Resident #7. The investigation found failures in reporting, investigating, protecting residents, and implementing corrective actions. The administrator failed to notify Adult Protective Services promptly and did not conduct thorough investigations. Protective measures such as immediate suspension of alleged abusers and 1:1 supervision were not implemented. The facility's behavior plans were inadequate and not updated to address aggressive sexual behaviors. These failures had the potential to affect 100% of residents.

The inspection was conducted as a health care complaint investigation to evaluate the facility's response to complaints and resident health care practices.

The facility failed to provide written responses to complaints, did not conduct nursing assessments for residents with changes in health status, inconsistently made recommendations for follow-up care, and lacked interventions to prevent recurrence of incidents such as falls.

The investigation was complaint-related, focusing on the facility's failure to respond to complaints and deficiencies in resident health assessments and care interventions.

The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings.

The survey identified multiple deficiencies including lack of documentation for testing of Alcohol-Based Hand Rub dispensers, staff and resident training on Emergency Action Plan roles, prohibited use of relocatable power taps with medical equipment and appliances, absence of policy for elimination of ignition sources related to medical gases, and incomplete documentation of emergency evacuation drills.

The inspection was a health care licensure and follow-up survey to verify compliance with regulatory requirements.

The facility was found to have multiple deficiencies including incomplete criminal history and background checks for employees, medication refrigerator temperatures out of range, lack of behavior plans for residents exhibiting certain behaviors, and missing documentation of current CPR and first aid certifications for employees.

The inspection was conducted as a health care complaint investigation to evaluate medication administration, resident health assessments, and staff delegation practices.

The facility failed to ensure residents received medications as ordered, did not conduct nursing assessments for residents with changes in health status, and had staff passing medications without proper delegation by the facility nurse.

The visit was complaint-related as indicated by the survey type 'health care complaint investigation'.

The inspection was conducted as a fire life safety and sanitation licensure survey for the facility Edgewood Spring Creek Eagle Island, LLC.

The inspection identified non-core issues including lack of documentation for testing Alcohol Based Hand Rub dispensers upon refill, missing sensitivity testing for the addressable fire alarm system since 2015, and one unsecured oxygen cylinder in the memory care medication room which was corrected on site.