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Deficiency Records for Boulder Creek Post Acute
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.
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? |
|---|---|---|---|---|
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Use approved construction type or materials. | Fire Safety | 2025-02-26 | 2025-03-26 | N |
| Dispose of garbage and refuse properly. | Health | 2025-02-14 | 2025-03-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2025-02-14 | 2025-03-14 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2025-02-14 | 2025-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-14 | 2025-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-02-14 | 2025-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-02-14 | 2025-03-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-02-14 | 2025-03-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-02-14 | 2025-03-14 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2025-02-14 | 2025-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-14 | 2025-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-02-14 | 2025-03-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2025-02-14 | 2025-03-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2025-02-14 | 2025-03-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-02-14 | 2025-03-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2025-01-13 | 2025-01-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-09 | 2024-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-09 | 2024-08-12 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-24 | 2024-05-30 | Y |
| 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 |
| 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 |
| Ensure proper usage of power strips and extension cords. | 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 |
| Have properly installed electrical wiring and gas equipment. | 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 |
| Install corridor and hallway doors that block smoke. | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Conduct testing and exercise requirements. | 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 |
| 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 |
| 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 |
| Use approved construction type or materials. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Provide emergency officials' contact information. | 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 |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-25 | 2022-06-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 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 |
| 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 |
| 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 |
| 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 organize and participate in resident/family groups in the facility. | 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-20 | 2022-06-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-20 | 2019-12-23 | N |
| Provide primary/alternate means for communication. | 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 |
| Install corridor and hallway doors that block smoke. | 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 |
| 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 |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 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 |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-31 | 2019-11-30 | 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 and implement an infection prevention and control program. | 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 |
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