Deficiency Records for Boulder Creek Post Acute
Updated as of March 01, 2021
This is not the most recent data for Boulder Creek Post Acute. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-11-03 | 2020-11-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-10-06 | 2020-10-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-21 | 2020-10-15 | Y |
| 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 | 2020-08-31 | 2020-09-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-09-09 | 2020-09-09 | Y |
| 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 | 2020-09-09 | 2020-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-05-26 | 2020-08-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-06-08 | 2020-06-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-13 | 2020-04-24 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2020-02-24 | 2020-03-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-27 | 2020-03-10 | Y |
| 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 | 2020-02-27 | 2020-03-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-27 | 2020-03-10 | Y |
| Provide primary/alternate means for communication. | 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 |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-18 | 2019-11-15 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-10-18 | 2019-11-15 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-10-18 | 2019-11-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-18 | 2019-11-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-18 | 2019-11-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-21 | 2019-11-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-21 | 2019-11-01 | Y |
| 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 | 2019-08-29 | 2019-09-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-21 | 2019-09-12 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-08-21 | 2019-09-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-21 | 2019-09-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-21 | 2019-09-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-08-21 | 2019-09-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-21 | 2019-09-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-21 | 2019-09-12 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-08-21 | 2019-09-12 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-08-21 | 2019-09-12 | Y |
| 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 | 2019-07-22 | 2019-08-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-28 | 2019-07-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-20 | 2019-07-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-07-12 | Y |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-07 | 2019-04-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-07 | 2019-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-07 | 2019-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-07 | 2019-04-05 | Y |
| 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 |
| 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 |
| 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 | Y |
| 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-22 | 2019-01-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-11 | 2019-01-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-04 | 2018-11-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-04 | 2018-11-13 | Y |
| 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 | 2018-09-04 | 2018-11-13 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-27 | 2017-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-27 | 2017-08-30 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-27 | 2017-08-30 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-27 | 2017-08-30 | N |
