A list of the most recent deficiencies for Boulder Creek Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2023-12-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-27 | 2023-04-20 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-20 | 2022-06-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-20 | 2022-06-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-20 | 2022-06-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-20 | 2022-06-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-20 | 2022-06-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-20 | 2022-06-19 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-20 | 2022-06-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-05-20 | 2022-06-19 | N |
| Post nurse staffing information every day. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-05-20 | 2022-06-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-20 | 2022-06-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-06-19 | N |
| Keep all essential equipment working safely. | Health | 2022-05-20 | 2022-06-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-05-20 | 2022-06-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-20 | 2022-06-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-13 | 2022-05-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-08 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-03 | 2022-01-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-14 | 2021-10-29 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-31 | 2019-11-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-31 | 2019-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-31 | 2019-11-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-31 | 2019-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-11-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-31 | 2019-11-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-10-31 | 2019-11-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-31 | 2019-11-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-31 | 2019-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-30 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2019-10-31 | 2019-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-31 | 2019-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-10-22 | 2019-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-22 | 2019-04-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-22 | 2019-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-22 | 2019-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-22 | 2019-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-22 | 2019-04-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-22 | 2019-04-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-10-22 | 2019-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-22 | 2019-04-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-22 | 2019-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-22 | 2019-02-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide appropriate foot care. | Health | 2018-10-22 | 2019-02-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-10-22 | 2019-02-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-22 | 2019-02-28 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-10-22 | 2019-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-22 | 2019-02-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-22 | 2019-02-28 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2018-10-22 | 2019-02-28 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-10-22 | 2019-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-22 | 2019-02-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-22 | 2019-01-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-10-22 | 2019-01-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-10-22 | 2019-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-22 | 2019-01-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-10-22 | 2019-01-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-22 | 2019-01-14 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-10-22 | 2019-01-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-22 | 2019-01-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
