Public Record
Boulder Creek Post Acute
Operated by Madison Creek Partners
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 149
- Avg. residents per day
- 141.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 60
- Fire safety findings
- 36
- Inspections on file
- 10
- Last inspection
- 2025-02-14
*CMS
*CMS
*CMS
*CMS
Citations
60 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0924Generalpotential for harm
Put firmly secured handrails on each side of hallways.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0625Generalpotential for harm
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.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0584Generalpotential for harm
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.
- 0585Generalpotential for harm
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.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0675Generalpotential for harm
Honor each resident's preferences, choices, values and beliefs.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0732Generalpotential for harm
Post nurse staffing information every day.
- 0803Generalpotential for harm
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.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0790Generalpotential for harm
Provide routine and 24-hour emergency dental care for each resident.
- 0578Generalpotential for harm
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.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0804Generalpotential for harm
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- 0803Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0688Generalpotential for harm
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.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0676Generalpotential for harm
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- 0839Generalpotential for harm
Employ staff that are licensed, certified, or registered in accordance with state laws.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection14 deficiencies
555206 02/14/2025 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064 F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before…
Read full statement of deficiencies - View inspection reportInspectionFire Safety9 deficiencies
- View inspection reportInspection1 deficiency
- Inspection2 deficiencies
555206 07/09/2024 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064 F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted…
Read full statement of deficiencies - View inspection reportInspectionFire Safety1 deficiency
- Inspection1 deficiency
555206 12/14/2023 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064 F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents…
Read full statement of deficiencies - View inspection reportInspection1 deficiency
- View inspection reportInspectionFire Safety18 deficiencies
- Inspection20 deficiencies
555206 05/20/2022 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064 F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her…
Read full statement of deficiencies - Inspection21 deficiencies
555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064 F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN…
Read full statement of deficiencies
Showing the 10 most recent inspections. 1 earlier inspection is also on record.
Ownership
Madison Creek Partners
13nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Boulder Creek Post Acute?
- Boulder Creek Post Acute is a Medicare- and Medicaid-certified nursing home in Poway, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 555206.
- What is the CMS rating for Boulder Creek Post Acute?
- Boulder Creek Post Acute has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Boulder Creek Post Acute have?
- Boulder Creek Post Acute is certified for 149 beds. It serves an average of 141.3 residents per day.
- How many citations does Boulder Creek Post Acute have?
- Boulder Creek Post Acute has 60 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Boulder Creek Post Acute last inspected?
- Boulder Creek Post Acute was last inspected on February 14, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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