Inspection Reports for
Edgewood Spring Creek Overland
10139 W Overland Rd, Boise, ID 83709, ID, 83709
Back to Facility Profile9 Reports
Inspection Report — Jun 11, 2026
Routine
Date: Jun 11, 2026
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with applicable regulations.
Findings
Six deficiencies were identified related to designated smoking areas, fire and life safety standards, electrical installations, medication distribution, and prohibited applications. Some issues were previously cited.
Deficiencies (5)
.161.04 Designated smoking areas: the smoking area in back of the facility was not clearly marked or established within policy, lacking signage.
.404 Fire and life safety standards: the facility’s last fire alarm sensitivity test was on 3/16/2021, resulting in a gap of more than 5 years; the inspection had not been completed (previously cited 7/24/2023).
.405.01.a Electrical installations and equipment: two Multi-Plug Adapters were observed in use in room 37B (previously cited 7/24/2023).
.310.01.g Medication distribution system: Resident #3 did not have PRN hydrocodone-acetaminophen and mucus relief available; Resident #10 did not have PRN olanzapine and stomach relief available due to the facility changing pharmacies.
.405.04 Prohibited applications: the facility had two gas fireplaces not included in the fuel fired heating inspection/testing; the fireplaces were not inspected for safety.
Report Facts
date: Mar 16, 2021
date: Jul 24, 2023
Inspection Report — May 15, 2025
Routine
Date: May 15, 2025
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulations.
Findings
Two deficiencies were found related to psychotropic medication reviews and documentation of resident care assessments. The facility had incomplete six-month medication reviews and inconsistent documentation of assessments after resident falls.
Deficiencies (2)
.310.04.e. Psychotropic or Behavior Modifying Medication: two of four residents did not have six month psychotropic medication reviews completed and two of four residents' reviews did not include behavior updates.
.330.04.c.vii. Resident Care Records: the facility nurses assessed residents for changes in physical and mental conditions but did not consistently document these assessments, including after multiple resident falls.
Inspection Report — Dec 6, 2024
Complaint Investigation
Date: Dec 6, 2024
Visit Reason
A health care complaint investigation survey was conducted to determine compliance with licensing requirements.
Findings
The facility operated without a licensed administrator for 208 days, resulting in both non-core and core deficiencies related to the lapse of administrator licensing.
Deficiencies (2)
.215. Requirements for a facility administrator: the facility operated without a licensed administrator from 5/13/24 to 12/6/24, with the current administrator's license expired since 5/12/24 and the administrator unaware of the expiration.
.215.03. Lapse of administrator: the facility failed to retain a licensed administrator overseeing day-to-day operations for more than 30 days, operating without one for 208 days, resulting in a core deficiency.
Report Facts
: 208
: May 12, 2024
: Dec 6, 2024
Inspection Report — Jul 24, 2023
Life Safety
Date: Jul 24, 2023
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with safety standards and regulations.
Findings
Six deficiencies were identified related to electrical installations, prohibited power tap applications, fire and life safety standards including sprinkler and fire suppression system issues, resident room door latch, and medical gases storage and signage.
Deficiencies (5)
.405.01.a. Electrical Installations and Equipment: Multi-Plug Adapters were observed in use in the hair salon, Administrator's office, and resident rooms #3 and #29.
.405.02.c. Prohibited Applications: Relocatable Power Taps were used to provide power to appliances in the Dietary Manager's office, business manager's office, Administrator's office, and Medication room, which is prohibited.
.404. Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: The annual sprinkler inspection showed glycerin antifreeze exceeded maximum allowed concentration; monthly visual inspections of wet suppression system gauges and control valves were not documented since May 2023; sprinkler pendants were leaking and rusted; pipe in attic was leaking; ANSUL system cartridge was older than 12 years with no hydrostatic test documentation; and the class-K fire extinguisher was past due for hydrostatic testing.
.250.12.j. Resident Sleeping Rooms: The door to resident room #22 would not latch. Corrected on 7/24/23.
.405.03. Medical Gases: Eleven unsecured oxygen cylinders were observed in resident room #29, and precautionary signage stating 'Oxygen in use, No Smoking' was missing at resident room doors and adjacent corridors.
Report Facts
date: Mar 27, 2023
percentage: 52.6
date: May 1, 2023
date: Jun 19, 2023
year: 2008
count: 11
date: Jul 24, 2023
Inspection Report — Apr 7, 2022
Routine
Date: Apr 7, 2022
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Seven deficiencies were identified related to background checks, corrective actions for falls, notification of incidents, medication and treatment orders, resident health assessments, food protection management, and staff training certifications.
Deficiencies (7)
.009.06.c Use of previous criminal history and background check: three of four employees who required a state police background check did not have one completed; the ISP background checks were not completed.
.215.08.e Corrective action: the facility did not ensure appropriate corrective actions were put into place to prevent recurrence of falls for Residents #4 and #5; interventions were not implemented despite multiple falls.
.215.08.f Notification to licensing agency within one business day: the facility did not notify Licensing and Certification when Residents #3 and #5 fell requiring hospital assessment and treatment; incidents were not reported.
.305.02.b Current medication orders and treatment orders: the facility nurse did not ensure residents received medications and treatments as ordered; Resident #1 did not receive correct levothyroxine dose for over five months and Resident #6 did not receive the ordered controlled carbohydrate diet.
.305.03 Resident health status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status; change of condition assessments were not completed for Residents #3, #5, and #6.
.450 Requirements for food and nutritional care services: the facility did not have a certified food protection manager; confirmed by the administrator and kitchen manager.
.600.04.b Sufficient personnel: two caregivers who worked alone did not have current first aid training certifications; confirmed by the business office manager.
Report Facts
dates: Array
counts: Array
Inspection Report — Nov 4, 2021
Complaint Investigation
Date: Nov 4, 2021
Visit Reason
A health care complaint investigation survey was conducted to assess compliance with regulations and investigate alleged deficiencies.
Findings
Two deficiencies were identified related to monitoring patterns of incidents and updating negotiated service agreements to reflect current resident needs.
Deficiencies (2)
.215.08.g. Identify and Monitor Patterns: the administrator did not have a method for monitoring patterns of incidents and accidents and developing interventions to prevent recurrences, including multiple falls by Resident #3.
.320.01. Use of NSA: negotiated service agreements were not updated to reflect current resident needs such as hospice services, wound care, bathing, grooming, and eating assistance (previously cited 9/27/2017).
Inspection Report — Oct 10, 2019
Life Safety
Date: Oct 10, 2019
Visit Reason
A Fire Life Safety Survey was conducted to assess compliance with fire safety and sanitation licensure requirements.
Findings
Seven deficiencies were found related to sprinkler system maintenance, electrical installations, emergency lighting, use of portable heaters, exit door signage, fire drill documentation, and building penetrations.
Deficiencies (7)
.415.05 Automatic Fire Extinguishing System Service and Testing: the annual sprinkler inspection identified glycerin anti-freeze at 51.9%, exceeding the 48% maximum; monthly visual inspections of sprinkler gauges and control valves have not been documented since June 2019.
.405.01.b Electrical Installations and Equipment: three relocatable power taps were daisy chained in the Sprinkler Riser Room; multiplug adapters and non-grounded extension cords were in use in resident rooms #18 and #33A; a full-sized dryer was plugged into a relocatable power tap in the laundry room.
.405.05 Structure, Maintenance, Equipment to Assure Safety: the emergency light on the west side of the smoke barrier doors was non-operational.
.405.05.f Structure, Maintenance, Equipment to Assure Safety: a portable space heater was found under the desk in the nursing office.
.405.07 Exit Door Locks: signage at delayed egress doors was worn and not legible.
.410.02 Fire Drills: the facility was missing a first shift, first quarter 2019 fire drill; the first shift fire drill on 5/17/19 lacked a documented time; the first shift, third quarter fire drill lacked a documented date; a swing shift fire drill during the fourth quarter 2018 was documented at 10:45 PM, outside swing shift hours.
.250.01 Building Character: approximately five conduits above the IT wiring wall in the Sprinkler Riser Room were not properly sealed with intumescent fire putty.
Report Facts
percentage: 51.9
percentage: 48
count: 3
count: 5
Inspection Report — Sep 27, 2017
Routine
Date: Sep 27, 2017
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Three deficiencies were identified related to negotiated service agreements, mental illness training documentation, and ongoing resident care records.
Deficiencies (3)
.320.01 Use of negotiated service agreement: the NSA did not describe the level of assistance for ADL's, outside services or treatments for Resident #3 and Resident #4, including eating assistance and wound care coordination.
.630.02 Mental illness: three of seven employees reviewed did not have documentation of mental illness training.
.711 Ongoing resident care records: the facility did not ensure documentation about residents was included in their record; notes about changes of condition or behaviors were documented in the nurse notification log but not in residents' records.
Report Facts
: employees without mental illness training documentation
: employees whose records were reviewed
Inspection Report — Feb 12, 2016
Life Safety
Date: Feb 12, 2016
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with fire safety and sanitation regulations.
Findings
Four non-core deficiencies were identified related to fire extinguishing system service, electrical installations, medical gases, and exit door locks.
Deficiencies (4)
.415.05 Automatic Fire Extinguishing System Service and Testing: sprinkler inspection report does not show Antifreeze solution percentage.
.405.01.b Electrical Installations and Equipment: multi-plug adapter in use in room #4 and room #27.
.405.03 Medical Gases: unsecured oxygen cylinders found in room #4 and room #39.
.405.07 Exit Door Locks: delayed egress door located in the activity room would not start the irreversible process to unlock.
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