Inspection Reports for Edgewood Spring Creek Overland
10139 W Overland Rd, Boise, ID 83709, ID, 83709
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Inspection Report
Follow-Up
Deficiencies: 2
May 15, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with medication review and resident care record documentation requirements.
Findings
The facility was found deficient in completing six-month psychotropic medication reviews for some residents and in documenting assessments of residents' physical and mental condition changes, including fall incidents.
Deficiencies (2)
| Description |
|---|
| Two of four residents did not have six month psychotropic medications reviews completed and two of four residents' reviews did not include behavior updates. |
| Assessments for changes in residents' physical and mental conditions were not consistently documented, despite nurses stating assessments were done. |
Report Facts
Residents with incomplete psychotropic medication reviews: 2
Residents with incomplete behavior updates in medication reviews: 2
Fall incidents documented for Resident #5: 4
Fall incidents documented for Resident #4: 1
Fall incidents documented for Resident #6: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Oldfield | Survey Team Leader | Named as survey team leader conducting the health care licensure and follow-up inspection. |
| Gary Weaver | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 6, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation to determine compliance with licensing requirements, specifically regarding the facility administrator's licensure status.
Findings
The facility operated without a licensed administrator from May 13, 2024, to December 6, 2024, a period of 208 days, resulting in a core deficiency. The administrator's license expired on May 12, 2024, and she was unaware of the expiration.
Complaint Details
The complaint investigation found the facility failed to retain a licensed administrator for the day-to-day operations for more than 30 days, resulting in a core issue deficiency.
Severity Breakdown
core deficiency: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility operated without a licensed administrator for 208 days. | core deficiency |
Report Facts
Days without licensed administrator: 208
Response due date: Jan 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Serina Williams | Administrator | Named in deficiency for operating without a valid license |
| Megan Rideout | Survey Team Leader | Conducted the complaint investigation |
| Melvin Lu | Health Facility Surveyor | Surveyor involved in the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 8
Jul 24, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable safety codes and regulations.
Findings
Multiple deficiencies were identified including improper use of multi-plug adapters and relocatable power taps, non-compliance with NFPA 101 Life Safety Code regarding sprinkler system antifreeze levels and inspection documentation, leaking sprinkler pendants, outdated ANSUL system cartridge, overdue fire extinguisher hydrostatic test, a resident room door that would not latch (corrected during the visit), unsecured oxygen cylinders, and missing oxygen safety signage.
Deficiencies (8)
| Description |
|---|
| Multi-Plug Adapters (MPA) were observed in use in the hair salon, Administrator's office, and resident rooms #3 and #29. |
| Relocatable Power Tap (RPT) was used to power refrigerators in multiple offices and medication room, which is a prohibited application. |
| Non-compliance with NFPA 101 Life Safety Code including excessive glycerin antifreeze concentration, lack of monthly visual inspections documentation, leaking sprinkler pendants, leaking and rusted antifreeze system sprinkler pendants, leaking pipe in attic, and lack of correction documentation. |
| ANSUL hood suppression system cartridge was older than 12 years and no indication of hydrostatic testing on the system cylinder. |
| Class-K fire extinguisher was past due for hydrostatic test. |
| Door to resident room #22 would not latch (corrected on 7/24/23). |
| Eleven unsecured oxygen cylinders observed in resident room #29. |
| Missing precautionary signage stating 'Oxygen in use, No Smoking' at resident room doors and/or adjacent corridors where oxygen was in use. |
Report Facts
Facility License Number: RC-1009
Inspection Date: 07/24/2023
Number of unsecured oxygen cylinders: 11
Date of last annual sprinkler inspection: 3/27/2023
Glycerin antifreeze concentration: 52.6
Date of ANSUL system inspection: 6/19/2023
Date of last known visual inspection of wet suppression system gauges: May 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelia Sanders | Administrator | Named as facility administrator during inspection |
| Linda Chaney | Survey Team Leader | Led the fire life safety and sanitation licensure survey |
Inspection Report
Follow-Up
Deficiencies: 7
Apr 7, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with state regulations and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to complete required background checks for employees, inadequate corrective actions to prevent resident falls, failure to notify licensing agency of incidents, medication and treatment order noncompliance, lack of nursing assessments for changes in resident health status, absence of a certified food protection manager, and insufficient personnel training certifications.
Deficiencies (7)
| Description |
|---|
| Three of four employees who required a state police background check did not have one completed. |
| The facility did not ensure appropriate corrective actions were put into place to prevent recurrence of falls for Residents #4 and #5. |
| The facility did not notify Licensing and Certification when Resident #3 and Resident #5 fell, incidents requiring hospital assessment and treatment. |
| Residents did not receive medications and treatments as ordered, including Resident #1's incorrect levothyroxine dose and Resident #6's diet order not followed. |
| The facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status. |
| The facility did not have a certified food protection manager. |
| Two caregivers who worked alone did not have current first aid training certifications. |
Report Facts
Number of falls for Resident #4: 3
Number of falls for Resident #5: 9
Number of falls for Resident #5: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Weaver | Administrator | Named as facility administrator |
| Teresa McClenathan | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 4, 2021
Visit Reason
The inspection was conducted as a health care complaint investigation to evaluate concerns related to monitoring patterns of incidents and updating negotiated service agreements for residents.
Findings
The facility failed to monitor and develop interventions for recurring incidents such as resident falls, and did not update negotiated service agreements to reflect current resident needs, including hospice and wound care services.
Complaint Details
The visit was complaint-related, focusing on failure to monitor incident patterns and update service agreements. Substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| The administrator did not have a method for monitoring patterns of incidents and accidents and developing interventions to prevent recurrences, exemplified by repeated falls of Resident #3 without intervention. |
| Negotiated Service Agreements (NSA) were not updated to reflect the current needs of residents, such as hospice services, wound care, bathing, grooming, and eating assistance for Resident #1. |
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