Inspection visit

Health inspectionOctober 31, 2019

BOULDER CREEK POST ACUTECMS #55520621 citations on this visit

21 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 21 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not display respect for residents when: Residents Affected - Few 1. Staff did not announce themselves for one of 31 residents when entering one resident's room; (77) 2. Staff were rude and disrespectful to Resident 28 and staff spoke non-English in the presence of eight of eight CR residents. (28, CR 1, CR 2, CR 3, CR 4, CR 5, CR 6, CR 7, CR 8) These failures had the potential to devalue the residents' self-esteem and self-worth. Findings: 1. Per the facility's policy, titled Quality of Life-Dignity, dated August 2009, . 11.Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance . On 10/31/19 11:29 A.M. an observation was conducted with LN 3. LN 3 was followed into Resident 77's room, to examine a wound. LN 3 entered Resident 77's room without knocking or asking permission to enter. On 10/31/19 at 11:31 A.M., an interview was conducted with LN 3 outside Resident 77's room. LN 3 stated she should have knocked first to alert the resident and then she should have asked permission to enter the room. LN 3 stated announcing yourself and asking permission shows respect to the resident and she did not do that. On 10/31/19 at 12:31 P.M., an interview was conducted with the DON. The DON stated she expected all staff to knock and announce themselves when entering a resident's room. Per the facility's policy, titled Quality of Life-Dignity, dated August 2009, . 6. Residents' private space and property shall be respected at all times . A. Staff will knock and request permission before entering a resident's room . 2a. Resident 28's was admitted on [DATE] with diagnoses that include weakness per the facility's admission Record. On 10/31/19, a review of Resident 28's MDS (health status screening and assessment tool), Section Page 1 of 40 555206 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 Residents Affected - Few C, dated 8/1/19, indicated Resident 28's BIMS Summary Score (test for cognitive function) was 8 out of 15 (moderate cognitive impairment). On 10/30/19 at 9:38 A.M., an interview with Resident 28 was conducted. Resident 28 stated she had two incidents with CNA 24 at the facility. Resident 28 stated a few weeks ago, CNA 24 came into the bathroom after she turned on the call light, and he just stood there without helping her, and it made her feel awful. Resident 28 further stated recently, CNA 24 got smart with her. Resident 28 stated CNA 24's attitude made her mad and she told him to leave and not take care of her anymore. On 10/31/19, a confidential staff interview was conducted. The CS stated a month ago, Resident 28 told the CS about the incident involving CNA 24. The CS stated Resident 28 was sitting on the toilet waiting for help, when CNA 24 came into the bathroom, did not acknowledge Resident 28, and started to fix his hair in the mirror. The CS further stated Resident 28 asked him for help to change her brief and CNA 24 placed the brief on the bathroom's sink and left Resident 28's bathroom. The CS stated Resident 28 had another incident with CNA 24 one week ago where Resident 28 stated CNA 24 could not take care of her anymore. The CS stated she had not reported these incidences to the charge nurse or the DON. The CS stated the charge nurse and the DON should have been made aware because CNA 24 was not respectful to Resident 28 when he provided care. On 10/31/19 at 6:46 A.M., an interview with LN 23 was conducted. LN 23 stated she was the night shift charge nurse and worked with CNA 24. LN 23 stated she had not heard any complaints from residents regarding CNA 24's behavior. LN 23 stated when a CNA heard a resident's complaint regarding a staff member being disrespectful, staff should tell her and the DON. LN 23 further stated it was not fair for residents to be treated disrespectfully. On 10/31/19 at 12:59 P.M., an interview with the DON was conducted. The DON stated staff were expected to treat residents with respect while providing care. The DON further stated she had not been notified of the two incidences between CNA 24 and Resident 28 and staff were expected to report any concerns with staff to her. According to the facility's policy, titled Quality of Life-Dignity, Revised August 2009, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . 2b. A confidential interview with CRP was conducted. CRP stated when care was being provided to CR 6, staff talked in different languages, other than English. CRP stated she did not understand what staff were saying and felt staff may have been talking about her and found it to be disrespectful. CRP further stated the issue had been brought up in resident council, but she had not seen any changes with staff. A confidential interview with CR 1 was conducted. CR 1 stated he had experienced staff speak in different languages, other than English, when providing care, and found it to be disrespectful. A confidential interview with CR 2 was conducted. CR 2 stated staff speak in different languages, other than English all the time and found it to be rude. A confidential interview with CR 3 was conducted. CR 3 stated she had experienced staff speak in different languages, other than English, when providing care, and found it to be disrespectful. 555206 Page 2 of 40 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 Residents Affected - Few A confidential interview with CR 4 was conducted. CR 4 stated she had experienced staff speak in different languages, other than English, when providing care, and found it to be disrespectful. A confidential interview with CR 5 was conducted. CR 5 stated she had brought the issue of staff speaking in different languages, other than English, to administration. CR 5 stated it continues to happen, and found it to be rude. CR 5 further stated she experienced staff speaking non-English in the dining room at mealtimes as well. A confidential interview with CR 7 was conducted. CR 7 stated he had experienced staff speak in different languages, other than English, when providing care, and found it to be disrespectful. A confidential interview with CR 8 was conducted. CR 8 stated he had experienced staff speak in different languages, other than English, all the time including in physical therapy. CR 8 stated he found it to be very rude. On 10/28/19, a review of the facility's Resident Council Minutes, dated 7/10/2019, 8/14/19, and 9/11/19, indicated the concern of staff continuing to speak foreign language was discussed and brought to the attention of the facility. On 10/31/19 at 11:30 A.M., an interview with CNA 22 was conducted. CNA 22 stated only English could be spoken while providing care to residents because if a resident could not understand what was being said, it was disrespectful. On 10/31/19 at 11:40 A.M., an interview with LN 24 was conducted. LN 24 stated the policy of the facility was to not speak a foreign language to other staff in front of the residents. On 10/31/19 at 12:59 P.M., an interview with the DON was conducted. The DON stated staff were expected to speak English in resident care areas, and was a dignity issue for the residents when staff spoke non-English in front of them. According to the facility's policy, titled Quality of Life-Dignity, Revised August 2009, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality . 555206 Page 3 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update a Physician Order for Life-Sustaining Treatment (POLST) for one of two residents (50) reviewed for advanced directives. This failure had the potential for Resident 50 to not get her wishes met when receiving life-sustaining treatment. Findings: Resident 50 was admitted to the facility on [DATE] with diagnoses which included heart failure (a chronic condition in which the heart does not pump blood as well as it should) per the facility's admission Record. On 10/30/19, a review of Resident 50's paper chart was conducted. Resident 50's POLST, dated 11/25/15, indicated selective treatment, goal of treating medical conditions while voiding burdensome measures, was selected and signed by the physician on 11/25/15. On 10/30/19, a review of Resident 50's hospice documents, located in a separate binder, was conducted. Resident 50's POLST, dated 11/25/15, indicated revised as of 8/13/19-new one to be signed by the MD. Selective treatment was crossed out, and initialed. Comfort-focused treatment, primary goal of maximizing comfort, was selected. This POLST was signed by the physician on 11/25/15. On 10/30/19 at 8:04 A.M., an interview and record review was conducted with LN 21. LN 21 stated in an emergency, staff would look at the POLST in Resident 50's paper chart. LN 21 reviewed Resident 50's paper chart and hospice documents, and stated the POLST in the paper chart did not match the hospice's revised POLST. LN 21 stated Resident 50's POLST should have been updated and signed by the physician, because in an emergency Resident 50 could have received the wrong treatment. On 10/30/19 at 9:48 A.M., an interview and record review was conducted with LN 21. LN 21 stated she received the updated POLST from hospice. The POLST, dated 8/13/19, indicated Comfort-Focused treatment and was signed by the physician on 8/14/19. LN 21 stated it should have been placed in Resident 50's paper chart when it was updated. On 10/31/19 at 12:59 P.M., an interview with the DON was conducted. The DON stated Resident 50 should have had the updated POLST in her paper chart because in an emergency, the POLST would guide staff on Resident 50's wishes for life-sustaining treatment. According to the facility's policy, titled Physician Orders for Life Sustaining Treatment, dated November 2014, .The POLST .is designed to be a statewide mechanism for an individual to communicate his or her wishes about a range of life-sustaining and resuscitative measures. 555206 Page 4 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to develop and implement comprehensive person-center care plans to reflect four of 31 residents individual needs related to: 1. Resident 20's need for Range of Motion (ROM-staff assisted movement of the joints); 2. Resident 77's podiatry care and treatment; 3. Resident 65's dental needs; and, 4. Resident 51's use of a seat belt, when sitting up in his wheelchair. As a result, there was the potential for residents to receive inconsistent care due staff being unaware of the residents specific needs and the interventions required to meet those needs. Findings: 1. Resident 20 was admitted to the facility on [DATE], per the facility's admission Record. On 10/28/19 at 8:19 A.M., an observation and interview was conducted of Resident 20. Resident 20 was in bed eating breakfast, with a fall mat on the floor. Resident 20 stated she preferred to stay in bed, because she did not feel strong enough to get out of bed. On 10/28/19, a record review was conducted for Resident 20: Resident 20's quarterly MDS (an assessment tool), dated 7/22/19, indicated a BIMS (a cognitive assessment) score of 14 (13-15 indicates the resident is cognitively intact). Resident 20's functional status for Activities of Daily Living indicated two-person assist with bed mobility and assistance to the bathroom. Resident 20's physician orders, dated 10/12/19, indicated RNA three times a week to all planes (Movement of joints, top to bottom, front to back, and side to side). On 10/30/19 at 7:49 A.M., an interview and record review was conducted with the ADON. The ADON confirmed the physician's order, dated 10/12/19, was for Resident 20 to receive RNA three times a week. The ADON could not locate documented evidence a plan of care for Resident 20's ROM was developed. The ADON stated care plans were important to staff, so everyone provided consistent care. The ADON stated staff should have created a ROM plan of care for Resident 20, when the physician's order was received. 2. Resident 77 was admitted to the facility on [DATE], per the facility's admission Record On 10/28/19 at 10:27 A.M., an interview was conducted with Resident 77. Resident 77 stated a podiatrist (foot doctor) came to see him last week for a toe issue. Resident 77 stated the podiatrist ordered a treatment, saying staff were to soak his toe and apply medication or else he would lose his toenail, due to the infection. Resident 77 stated the staff had not yet soaked his toe and he was 555206 Page 5 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0656 afraid his toe infection would get worse. Level of Harm - Minimal harm or potential for actual harm On 10/29/19 a record review was conducted for Resident 77: Residents Affected - Some The physician's order, dated 10/24/19, indicated. Soak Right great toe in warm water with Epsom salts for ten minutes, pat dry, apply triple ointment cover with bandaid. One time a day every Mon. Wed. Fri. for ingrown toenail for two weeks, Start 10/25/19. A plan of care could not be located for Resident 77's right in-grown great toenail. On 10/31/19 at 11:27 A.M., an interview and record review was conducted with LN 3. LN 3 stated a person-centered plan of care should have been developed for Resident 77, when the nail infection was identified. LN 3 stated a plan of care was important for communication among staff, so the care provided was consistent. 3. Resident 65 was admitted on [DATE], per the facility's admission Records. On 10/28/19 at 8:54 A.M., an observation and interview was conducted with Resident 65, while he sat in a wheel chair beside his bed. Resident 65 had no teeth or dentures in his mouth. A partially consumed breakfast tray sat on a near-by table. Resident 65 stated he had been without teeth for over a year. Resident 65 stated when he arrived, they said they would try to get him dentures. Resident 65 stated he had not seen a dentist since he arrived. On 10/30/19, Resident 65's clinical record was reviewed: Resident 65's admission MDS (an assessment tool) dated 9/7/19, indicated Resident 65 had a BIMS (a cognitive assessment) score of 13, (score 13-15, indicates cognitively intact). The Facility's admission Assessment, dated, 8/31/19, indicated Resident 65 had no teeth or dentures, and his dentures were previously lost. The facility's admission Base Line Care Plan, dated 8/31/19, indicated Resident 65 was edentulous (without teeth). No goals or interventions were listed for potential chewing problems. The facility's Care Plan Conference Review, dated 9/2/19, indicating Resident 65 was edentulous and he did not have dentures. Resident 65's clinical record contained no documented evidence a long-term dental care plan had been initiated or developed. On 10/30/19 at 11:19 A.M., an interview was conducted with the ADON. The ADON stated Resident 65 should have had a care plan for dental issues, due to not having teeth and wanting dentures. The ADON stated a baseline care plan was for the initial admission assessment, so resident's immediate needs could be met. A person-centered plan of care would have addressed potential chewing problem and the need for a dental referral. On 10/31/19 at 12:31 P.M., an interview was conducted with the DON. The DON stated individualized care plans were important so residents received consistent care. The DON stated she expected care plans to be developed for any issues that had the potential to cause harm, or for current issues 555206 Page 6 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0656 identified. Level of Harm - Minimal harm or potential for actual harm Per the facility's policy, titled Care Planning-Interdisciplinary Team, dated December 2016, .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . g. Incorporate identified problem area .k. Reflect treatment goals . Residents Affected - Some 4. Resident 51 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease (a disorder that affects movement) and dementia (decline in memory, language, and other thinking skills) per the facility's admission Record. On 10/30/19, a review of Resident 51's MDS (health status screening and assessment tool) Section C, dated 8/16/19, indicated Resident 51 had severe cognitive impairment for daily decision making. On 10/28/19 at 8:58 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/29/19 at 8:11 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/29/19 at 8:17 A.M., an observation and interview with CNA 21 was conducted. CNA 21 observed Resident 51's seatbelt. CNA 21 stated to unlatch the seatbelt, someone would need to press the release button. CNA 21 further stated Resident 51 could not remove the seatbelt on his own. On 10/30/19 at 8:55 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/30/19 at 10:13 A.M., a joint observation and interview with LN 21 and Resident 51 was conducted. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. LN 21 asked Resident 51 in his native language if he could remove the lab belt. Resident 51 replied no per LN 21' s translation. On 10/30/19 at 10:20 A.M., an interview and record review with LN 21 was conducted. LN 21 reviewed Resident 51's medical record and could not find any care plans or documentation related to the seatbelt. On 10/30/19 at 10:57 A.M., an interview with the DON was conducted. The DON stated Resident 51 had used the wheelchair with the seatbelt for one year. The DON stated there should be a care plan so staff were aware of the seatbelt. According to the facility's policy, titled Care Plans, Comprehensive Person-Centered, Revised December 2016, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s psychosocial and functional needs is developed and implemented for each resident . 555206 Page 7 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meal assistance to one of five residents (17) reviewed for ADLs. Residents Affected - Few This failure had the potential to result in Resident 17 to experience a decrease in ADLs and weight loss. Findings: Resident 17 was admitted on [DATE], with diagnoses which included dysphagia (difficulty swallowing food or liquids) and muscle weakness per the facility's admission Record. On 10/30/19, a review of Resident 17's MDS (an assessment tool) Section C, dated 10/14/19, indicated Resident 17's BIMS Summary Score (test for cognitive function) was 2 out of 15 indicating severe cognitive impairment. On 10/28/19 at 8:26 A.M., an observation and interview with Resident 17 was conducted. Resident 17 was lying in her bed, with a breakfast tray on her bedside table. The bedside table was angled away from Resident 17. The food on the tray was uncovered, and two drinks on the tray had plastic covering the tops of them. Resident 17 stated she could not eat on her own and someone needed to help her eat. On 10/28/19 at 8:30 A.M., an observation and interview with CNA 25 was conducted. CNA 25 entered Resident 17's room, removed the plastic covering from the two drinks, and began feeding Resident 17. CNA 25 stated Resident 17 received her tray earlier, around 7:15 A.M. or 7:30 A.M., but she could not feed her at that time because she had other residents to help. CNA 25 stated she came in to check Resident 17 and noticed no one had assisted Resident 17 with her breakfast. CNA 25 stated Resident 17 should have been fed right away when her tray arrived, because she could not feed herself. On 10/28/19, a review of Resident 17's care plan was conducted. A care plan, revised 2/28/19, indicated Resident 17 had an ADL self-care performance deficit and was a total assist with eating. On 10/30/19 at 1:56 P.M., an interview with LN 5 was conducted. LN 5 stated residents who need assistance with their meals should be assisted within 15 minutes of getting their tray. LN 5 stated all nursing staff were expected to assist residents with meals if it were needed. On 10/31/19 at 12:59 P.M., an interview with the DON was conducted. The DON stated residents that need assistance with meals, she expected nursing staff to assist residents right when staff drop off the tray. The DON further stated Resident 17 should have been assisted and should not have waited an hour for assistance. According to the facility's policy, titled Activities of Daily Living (ADLs), Supporting, Revised March 2018, .Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: .d. Dining (meals and snacks) . 555206 Page 8 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not implement a physician's order for an ophthalmology (a doctor with specialization of eye treatment including surgery) referral for one of three residents reviewed for vision (59). Residents Affected - Few As a result, Resident 59 had the potential for low vision or decreased vision. Findings: Resident 59 was admitted to the facility on [DATE] per the facility's admission Record. On 10/28/19 at 1:01 P.M., an interview with Resident 59 was conducted. Resident 59 stated she had been asking staff about her eye appointment, but had not received any response. On 10/29/19 at 4:07 P.M., an interview with the SSD was conducted. The SSD stated she had to check the Optometrist (provides eye health/ may provide glasses) book. The SSD stated she did not make ophthalmology appointments for residents. On 10/30/19 at 11:30 A.M., an interview with the SSD was conducted. The SSD stated she had not followed up on the appointment for Resident 59 because she had another priority to deal with first. The SSD also stated she thought it was the optometrist's fault there was no referral. The SSD further stated she did not document phone calls made for residents' appointments and did not maintain a log. On 10/30/19 at 2:04 P.M., a joint interview and record review with LN 5 was conducted. An active physician's order, dated 8/24/19, indicated ophthalmology consult and treatment as indicated. LN 5 stated she was unable to locate an appointment arrangement, for Resident 59's ophthalmology referral dated 8/24/19. An additional physician's order was reviewed with LN 5 for Resident 59, dated 9/30/19, Ophthalmologist consult, Right eye impaired vision. LN 5 stated she was unable to locate an appointment arrangement for Resident 59's, ophthalmology referral dated 9/30/19. LN 5 reviewed the SSD notes and was unable to locate any documentation regarding Resident 59's requests for eye appointments. On 10/30/19 at 2:55 P.M., a joint interview and record review with the CM was conducted. The CM stated Resident 59 had physicians' orders for eye referrals on 8/24/19 and 9/30/19. The CM further stated she was unable to locate any appointment arrangements made for Resident 59 in regards to the physicians' orders for eye referrals. On 10/30/19 at 2:16 P.M., an interview with Resident 59 was conducted. Resident 59 stated she still wanted an eye appointment. Resident 59 stated she only saw gray colors and thought she might have a cataract (a cloudy lens). Resident 59 stated she and her daughter both asked the SSD eight times for help to make the eye appointment. Per the facility Job Description of the SSD, with date of hire 3/18/19, .Record and maintain regular Social Service progress notes indicating response to treatment plan and/or adjustment to 555206 Page 9 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0685 institutional life .Assist in making appointments for the resident/family as requested or appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555206 Page 10 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide Restorative Nursing Services (RNA-CNAs with specialized training to help improve residents' strength and mobility), as ordered by their physician for one of five residents reviewed for Activities of Daily Living. (20) This failure had the potential to affect Resident 20's highest level of function and possible result in avoidable decline of Range of Motion (ROM). Findings: Resident 20 was admitted to the facility on [DATE], with diagnoses, which included heart failure (heart can't pump blood to the rest of the body with enough force), per the facility's admission record. On 10/28/19 at 8:19 A.M., Resident 20 was observed and interviewed. Resident 20 was in bed eating breakfast. Resident 20 stated she preferred to stay in bed, because she did not feel strong enough to get out of bed. On 10/28/19. Resident 20's clinical record was reviewed. The quarterly MDS (an assessment tool), dated 7/22/19, indicated a BIMS (a cognitive assessment) score of 14 (13-15 indicates the resident is cognitively intact. Resident 20's functional status for Activities of Daily Living indicated two-person assist with bed mobility and assistance to the bathroom. Resident 20's physician orders, dated 10/12/19, indicated RNA three times a week to all planes (Movement of joints, top to bottom, front to back, and side to side). On 10/30/19 a subsequent record review was conducted for Resident 20. No documented evidence could be located of RNA being initiated or performed. On 10/30/19 at 7:45 A.M., an interview and record review was conducted with RNA 3 in the physical therapy room. RNA 3 stated when a physician made a RNA order, the RNA staff received a printed form with the order from the LNs or else from the PTD. RNA 3 stated the RNA order would also be added to the Resident 20's MAR. RNA 3 further stated the RNAs documented the treatment in the MAR, as soon as the treatment was performed. RNA 3 reviewed the RNA binder book and stated he could not find a physician's order or a MAR for Resident 20 to receive RNA services. On 10/30/19 at 7:49 A.M., an interview and record review was conducted with the ADON. The ADON confirmed the physician's order, dated 10/12/19, was for Resident 20 to receive RNA three times a week. The ADON stated the order was entered by the PTD at 3:49 P.M. on 10/12/19. The ADON stated the PTD should have printed out the order for RNA staff and then a MAR would have been generated. The ADON reviewed Resident 20's MAR for October 2019, and could not find any evidence RNA treatments were documented on the MAR. The ADON stated if RNA was not entered into the MAR, then staff were never informed, which meant RNA therapy was never initiated by staff. 555206 Page 11 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/30/19 at 8:04 A.M., and interview and record review was conducted with the PTD. The PTD stated she received the physician's order for Resident 20 to begin RNA therapy three times a week. The PTD stated since Resident 20's RNA order was not in the RNA book; she assumed she had never printed out the order to inform the staff of Resident 20's RNA treatment plan. The PTD stated the purpose of RNA and ROM was to maintain or improve a resident's flexibility and strength. The PTD stated Resident 20 missed out on two weeks of RNA therapy, because RNA staff were never informed of the order. On 10/30/19 at 9:05 A.M., an interview was conducted with the DON. The DON stated Resident 20's need to receive RNA services did not occur, based on poor communication. The DON stated Resident 20 could have experienced a decline in her ROM. Per the facility's policy, titles Restorative Nursing Services, dated July 2017, Resident will receive restorative nursing care as needed to promote optimal safety and independence. Per the facility's policy, titled Range of motion Exercises, dated October 2010, . 1. Verify that there is a physician's order for this procedure .Documentation .record in the resident's medical record . 1. The date and time the exercises were performed . 555206 Page 12 of 40 555206 10/31/2019 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed asess two of three residents reviewed for accident hazards (51, ) when: 1. Resident 51 had not documentation or assessment for a safety device and, These failures had the potential to result in physical harm. Findings: Resident 51 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (a disorder that affects movement) and dementia (decline in memory, language, and other thinking skills) per the facility's admission Record. On 10/30/19, a review of Resident 51's MDS (health status screening and assessment tool) Section C, dated 8/16/19, indicated Resident 51 had severe cognitive impairment for daily decision making. On 10/28/19 at 8:58 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/29/19 at 8:11 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/29/19 at 8:17 A.M., an observation and interview with CNA 21 was conducted. CNA 21 observed Resident 51's seatbelt. CNA 21 stated to unlatch the seatbelt, someone would need to press the release button. CNA 21 further stated Resident 51 could not remove the seatbelt on his own. On 10/30/19 at 8:55 A.M., an observation of Resident 51 was conducted in his room. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. On 10/30/19 at 10:13 A.M., a joint observation and interview with LN 21 and Resident 51 was conducted. Resident 51 was sitting in his wheelchair and a two-point seatbelt was observed buckled across his hips. LN 21 asked Resident 51 in his native language if he could remove the lab belt. Resident 51 replied no per LN 21's translation. On 10/30/19 at 10:20 A.M., an interview and record review with LN 21 was conducted. LN 21 reviewed Resident 51's medical record and could not find any orders, assessments, care plans, or monitoring documentation related to Resident 51's seatbelt. LN 21 stated there should be an order, assessments, care plans for Resident 51's seatbelt. LN 21 stated the seatbelt should be because the seatbelt restricted Resident 51's movement. LN 12 further stated Resident 51 was at risk for an injury if he were to fall forward. On 10/30/19 at 10:57 A.M., an interview with the DON was conducted. The DON stated Resident 51 had used the wheelchair with the seatbelt for one year. The DON stated there should be an assessment of the seatbelt because the seatbelt put Resident 51 at risk for injury. 555206 Page 13 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0689 Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, titled Safety and Supervision of Residents, Revised July 2107, .Resident safety .and assistance to prevent accidents are facility-wide priorities . 2. The interdisciplinary care team shall analyze informatoin obtained from assessments adn observations to identify any specific accident hazars or risks for individual residents . Residents Affected - Few 555206 Page 14 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four residents reviewed for urinary catheters and urinary infections had: 1. Secured urinary catheters (a device inserted into the bladder to drain urine) drainage tubes for Residents 45 and 279, 2. A urinal (a plastic container used to collect urine) provided to Resident 6 to promote independence. These failure had the potential for the urinary catheters to be pulled out of the urinary canal which would cause pain. There was the potential for Resident 65 to have a urinary infection that went untreated, and for Resident 6 to not achieve their highest practicability of independence when a urinal was not routinely provided. Findings: 1a. Resident 45 was re-admitted to the facility on [DATE] with diagnoses which included obstructive uropathy (urine can't be expelled from the urinary system due to some type of obstruction), per the facility's admission Record. A review of Resident 45's clinical record was conducted on 10/30/19. The Order Summary report, dated 10/30/19, indicated Resident 45 had a physician's order for a urinary catheter and catheter care, initiated 8/20/19. On 10/28/19 at 9:18 A.M., a joint interview and observation was conducted with Resident 45. Resident 45 stated his catheter had pulled out twice and most of the time staff did not secure it to his leg. The catheter was observed to not be secured to Resident 45's leg. On 10/28/19 at 9:21 A.M., an interview and concurrent observation of Resident 45 was conducted with LN 31. LN 31 acknowledged the catheter was not secured to a leg band. LN 31 asked Resident 45 if he would like the catheter secured to his leg and he replied, Yes, if it would help me not pull it out. 1b. Resident 279 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, per the facility's admission Record. A review of Resident 279's clinical record was conducted on 10/29/19. The Order Summary Report, dated 10/31/19, indicated Resident 279 had a physician's order for a urinary catheter and catheter care initiated on 10/9/19. On 10/28/19 at 10:59 A.M., a joint observation of Resident 279 and interview with LN 31 was conducted. LN 31 observed Resident 279 had a leg band device for his urinary catheter, but the catheter was not attached to the leg band clip. LN 31 tried to attach the catheter but the clip did not work. 555206 Page 15 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/28/19 at 11:05 A.M., a concurrent observation of Resident 279 and interview with CNA 32 was conducted. CNA 32 acknowledged the leg band clip was broken. CNA 32 stated, Something should have been said to the nurse. On 10/31/19 at 9:40 A.M., an interview was conducted with the DON. The DON stated it was the facility's policy to secure catheter tubes to leg bands to prevent them from being pulled out. Per the facility's policy titled, Catheter Care, Urinary, revised September 2014, .Secure catheter utilizing a leg band . 2. Resident 6 was admitted on [DATE], with diagnoses that included congenital malformations of skin (skin disorder present since birth) per the facility's admission Record. On 10/29/19 at 8:48 A.M., an observation and interview with Resident 6's RP was conducted. Resident 6 was lying in bed, with a brief (underwear for incontinence) on. The RP stated Resident 6 had a disease on his skin that created sores, and Resident 6 was confused at times. The RP stated Resident 6 could use the bedside urinal when it was offered. The RP stated she did not know why staff had been placing Resident 6 in a brief for the last two weeks. The RP stated the brief was making Resident 6's skin sores irritated. On 10/30/19 at 7:51 A.M., a subsequent observation and interview with Resident 6's RP was conducted. Resident 6 was lying in bed, with a brief on. The RP stated when she comes to visit Resident 6, if a urinal is present it was usually was out of reach for Resident 6 to use. The RP stated Resident 6 would use the bedside urinal, if it were offered and reachable, but staff did not offer the urinal consistently. On 10/31/19 at 7:55 A.M., an interview with CNA 26 was conducted. CNA 26 stated Resident 6 could use the bedside urinal and the bathroom. CNA 26 stated when she started her shift, Resident 6 would have a brief on, but she would remove it after Resident 6 received a shower, and not place another a brief on for the rest of her shift. CNA 26 further stated she had a hard time removing his brief in the mornings because it would get stuck to Resident 6's skin sores. CNA 26 stated if staff were to offer Resident 6 his bedside urinal or the bathroom every two hours he would not need a brief. On 10/31/19 at 8:09 A.M., an interview and record review with LN 5 was conducted. LN 5 stated Resident 6 was continent of urine on admission, and would use his bedside urinal and the toilet when it was offered. LN 5 further stated she did not know if Resident 6 was always continent or why other shifts placed Resident 6 in a brief. LN 5 reviewed Resident 6's Bladder and Bowel assessment, dated 9/27/18, and stated Resident 6 voids without incontinence always, and incontinent of stool never. LN 5 stated Resident 6 should be offered the bedside urinal or the toilet every two hours to promote Resident 6's independence and to help his skin. On 10/31/19 at 12:59 P.M., an interview with the DON was conducted. The DON stated Resident 6 was continent and staff should be offering the bedside urinal or the toilet so he could use it to promote his independence. The DON stated if staff did see a decline, and Resident 6 was no longer continent, he should be on a bowel and bladder program for scheduled toileting to help with continence. According to the facility's policy, titled Urinary Incontinence-Clinical Protocol, Revised April 2018, .3. The staff will identify environmental interventions and assistive devices (e.g.urinals .) that facilitate toileting .4. As appropriate, based on assessment .the staff will provide scheduled 555206 Page 16 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0690 toileting, prompted voiding, or other interventions to try to improve the individual's continence status . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555206 Page 17 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to monitor one of five residents reviewed for nutrition (78). Residents Affected - Few As a result Resident 78 experienced altered nutrition and experienced a significant weight loss. Findings: On 10/28/19 at 9:52 A.M., an interview was conducted with Resident 78. Resident 78 stated although he had a gastrostomy tube (feeding tube) in place, recently the tube was no longer used to provide nutrition to his body since he started eating by mouth. Resident 78 stated the facility had not weighed him since the beginning of the month. On 10/30/19 at 1:21 P.M., LN 13 was interviewed. LN 13 stated his appetite was coming back now that he was eating by mouth. Resident 78's record was reviewed: Per the Weights and Vitals Summary document dated 10/31/19. Resident weights were as follows: 8/1/19 174 lbs 9/1/19 172 lbs 10/01/19 159 lbs Resident 78's weight from 9/1/19 to 10/1/19 was not recorded on the summary document. Per Resident 78's care plan dated 2/26/19: Focus: At risk for losing weight .Goal: minimize any unplanned weight changes daily, Interventions: monitor weights as ordered, RD to follow up as indicated. Interventions: Report significant weight loss to MD and family. Resident 78's progress notes were reviewed. Per the late entry dated 10/3/19, RD 1 documented a IDT Weight Committee Note. Per the note, Resident 78 had a weight loss of 7.6% of his total body weight in one month. Per the document, RD and IDT were to monitor resident weights, labs, and intake closely. Resident 78's Progress notes, titled Change of Condition Note dated 10/4/19 , LN 2 documented Resident 78 to have lost 13 lbs in one month and a requested for a dietary consult was written by LN 2. On 10/31/19 at 7:58 A.M., a joint interview and record review was conducted with RD 2. RD 2 stated based on Resident 78's recorded weights, Resident 78 had experienced a severe weight loss. RD 2 stated Resident 78 should have been placed on weekly weights and more weight loss interventions should have been put in place after the significant weight loss was noticed on 10/3/19. RD 2 stated more interventions such as tracking Resident 78's intake, meal preferences, and follow up regarding change of condition should have occurred. RD 2 stated the weight loss team did not follow up and discuss Resident 78's significant weight loss for the rest of the month (October 2019). 555206 Page 18 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/31/19 at 12:51 P.M., an interview was conducted with the DON. The DON stated Resident 78 should have been monitored and provided additional interventions to address the weight loss and to ensure Resident 78's did not continue to lose weight. According to the facility's policy, titled Weight Assessment and Intervention, revised September 2008: .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 555206 Page 19 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented when a physician's order was not followed for the use of a humidifier (moisturized oxygen) with oxygen for one of three residents (62) reviewed for respiratory care. Residents Affected - Few This failure caused Resident 62 to have an dry throat. Findings: Resident 62 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by shortness of breath, wheezing, or a chronic cough), and the need for supplemental oxygen per the facility's admission Record. Resident 62's clinical record was reviewed on 10/31/19. The Order Summary Report, dated 10/31/19, indicated an order was initiated on 7/9/19 for Humidified oxygen at 2 LPM (liters per minute) via Nasal Cannula (device to deliver oxygen directly into the nostrils) every shift for COPD. On 10/28/19 at 8:30 A.M., a joint observation and interview was conducted with Resident 62. Resident 62 was observed wearing a nasal cannula providing supplemental oxygen via an oxygen concentrator (turns room air into highly concentrated oxygen). The concentrator did not have a humidifier bottle attached. Resident 62 stated, I should have a humidifier on my oxygen. I woke up this morning and my throat was so dry I could hardly talk. On 10/28/19 at 8:35 A.M., a joint observation of Resident 62, and interview with LN 31 was conducted. LN 31 acknowledged there was no humidifier attached to Resident 62's concentrator. On 10/28/19 at 8:49 A.M., an interview was conducted with LN 31. LN 31 confirmed there was an order for a humidifier and it had been missed. On 10/28/19 at 8:55 A.M., an interview was conducted with the DON. The DON confirmed there was an order for a humidifier for Resident 62 and stated not having the humidifier could dry out Resident 62's nasal passage and throat. Per the facility's policy, titled Oxygen Administration, revised October 2010, .guidelines for safe oxygen administration .the following equipment and supplies will be necessary .humidifier bottle . 555206 Page 20 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two residents (16, 49) reviewed for pain were administered adequate pain medication when: Residents Affected - Few 1. Resident 16 did not receive a physician ordered Lidocaine (slowly released pain medication) patch as scheduled five times in October 2019 and, 2. Resident 49 did not receive adequate pain medication for scheduled pressure ulcer and range of motion (ROM - exercises to decrease contractures, defined as shortening and hardening of muscles, tendons, or other tissue, often leading to deformity) treatments. These failures placed both Residents' 16 and 49 at risk for unnecessary pain. Findings: 1. Resident 16 was re-admitted to the facility on [DATE] with diagnoses which included fibromyalgia (causes aching and deep stabbing pain) per the facility's admission Record. Resident 16's clinical record was reviewed on 10/29/19. The Order Summary Sheet, dated 10/31/19, indicated an order was initiated on 10/8/19 for a Lidocaine patch 5%, Apply to affected area topically in the morning for PAIN . Progress Notes for the month of October 2019 were reviewed. The notes indicated that on three occasions (10/4/19, 10/9/19, and 10/10/19) the Lidocaine patch was not available for administration. On 10/4/19 and 10/10/19 the progress notes indicated Awaiting for [pharmacy name] delivery. The note on 10/9/19 indicated Requested refill from [pharmacy name]. The MAR for October 2019 indicated that Resident 16 was in 6 out of 10 pain (0-10 pain scale: 1-4 indicates mild pain, 5-7 indicates moderate pain, 8-10 indicates severe pain) the evening of 10/9/19 and 7 out of 10 pain the morning of 10/10/19. On 10/29/19 at 9 A.M., an interview was conducted with Resident 16. Resident 16 stated she used a Lidocaine patch daily and they had been running out of the medication. Resident 16 stated it usually takes a day to get a new one when they run out. Resident 16 stated, I have been taking this patch for a long time and they should not be running out. On 10/31/19 at 8:30 A.M., an interview was conducted with the CM. The CM stated it takes the pharmacy one to two days to get medicines to us. We do not have to wait for a physician's signature to get additional Lidocaine. The CM stated, Nurses aren't ordering it quick enough. On 10/31/19 at 8:35 A.M., an interview was conducted with LN 2. LN 2 stated Resident 16 was in her section and she took care of her regularly. LN 2 stated, It is the nurse's job to put in an order when we are running low. LN 2 stated it takes about one or two days to get Lidocaine patches from the pharmacy. LN 2 stated Resident 16 got a new patch every 24 hours, so an order should be faxed to the pharmacy at least three days before running out. LN 2 acknowledged nurses were not ordering the patches quick enough. 555206 Page 21 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/31/19 at 9:47 A.M., a joint interview and record review was conducted with the DON. The DON acknowledged that on several occasions in October, Resident 16 had not received her scheduled Lidocaine patch. The DON stated this could cause Resident 16 unnecessary pain. 2. Resident 49 was re-admitted to the facility on [DATE] with diagnoses which included dementia (memory loss) and a stage 4 pressure ulcer (bed sore with severe tissue damage that extends into muscle and bone) per the facility's admission Record. Resident 49's clinical record was reviewed on 10/30/19. The Order Summary Report, dated 10/31/19, indicated an order was initiated on 7/20/19, to provide ROM three times per week to the upper body and five times per week to the lower body. The Order Summary Report, dated 10/31/19, indicated Resident 49 was admitted to hospice care on 8/23/19 (supportive care given to people in the final phase of a terminal illness to make them comfortable and free of pain). The Order Summary Report, dated 10/31/19, indicated a new order was initiated on 10/24/19 to treat Resident 49's existing pressure ulcer wound every day during the day shift, 7 A.M. to 3:30 P.M., for 21 days. Resident 49's care plans indicated the following focus areas/interventions were identified: 1. Resident was non-verbal related to dementia, revised 8/29/19, with an intervention to Monitor/document for physical/non-verbal indicators of discomfort or distress, and follow-up as needed. 2. Resident was at risk for pain when wound care was rendered, and was initiated on 7/19/19, with an intervention to Give adequate analgesia (pain medication) half hour prior to wound care/dressing change . An additional intervention was Licensed Nurse/Treatment nurse to monitor for non-verbal (facial grimacing, guarding) S/S (signs and symptoms) of pain and discomfort during wound treatment and medicate as needed. 3. Resident was at risk for alteration in musculoskeletal status related to contractures, revised 7/29/19, with an intervention to Give analgesia as ordered by the physician . The Order Summary Report, dated 10/31/19, indicated orders were started on 7/13/19 to: 1. Monitor for pain before treatments rendered every day shift. 2. Monitor for pain post treatment rendered every day shift. 3. Norco Tablet (hydrocodone/acetaminophen - an opioid pain reliever), 5-325 MG, give one tablet by mouth every day shift for wound management prior to treatment rendered. 3. Norco Tablet, 5-325 MG, give one tablet by mouth every six hours as needed for mild to moderate pain. 4. Norco Tablet, 5-325 MG, give two tablets by mouth every six hours as needed for severe pain. 555206 Page 22 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0697 The Order Summary Report, dated 10/31/19, indicated additional pain medications were started on 9/14/19 as needed for: Level of Harm - Minimal harm or potential for actual harm 1. Morphine Sulfate (an opioid pain reliever) .give 0.25 ml every four hours as needed for mild pain . Residents Affected - Few 2. Morphine Sulfate .give 0.5 ml every four hours as needed for moderate pain . 3. Morphine Sulfate .give 1.0 ml every four hours as needed for severe pain . The Restorative Nursing Weekly Summary (documentation of Resident 49's ROM treatments) indicated on 9/20/19: 1. Did the resident tolerate the treatment well? NO 2. Did the resident complain of pain? YES Summary/Conclusion - Resident shows refusal with her RNA (specialized training to perform ROM) program by grimacing and pushing me away from her, charge nurse is notified. The Restorative Nursing Weekly Summary indicated on 10/4/19, 10/11/19, 10/18/19, and 10/25/19 Resident 49 exhibited pain. The 10/11/19 report summary/conclusion indicated resident is very contracted .it's hard for her to move . In each case documentation indicated the nurse was made aware. The MAR for the months of September 2019 and October 2019, indicated that none of the as needed pain medications available had been administered to Resident 49. On 10/28/19 at 9:50 A.M., an observation was conducted of Resident 49. Resident 49 was observed to be in bed and was grimacing. On 10/28/19 at 1:05 P.M., another observation was conducted of Resident 49. Resident 49 looked uncomfortable and was grimacing. On 10/29/19 at 1:30 P.M., a joint observation of Resident 49, and an interview with LN 33 was conducted. LN 33 was observed helping the NP perform a treatment on Resident 49's pressure ulcer. Resident 49 was observed flinching, moaning, and grimacing. LN 33 acknowledged Resident 49 appeared to be in pain. On 10/29/19 at 1:40 P.M., an interview was conducted with LN 42. LN 42 stated Resident 49 gets a Norco daily for treatment, but she stated I never know when to give it, the treatment nurses are not very good at communicating to me when they are going to be doing the treatment. On 10/29/19 at 3:09 P.M., a joint interview and record review was conducted with LN 33. LN 33 stated she told the nurse when she was going to do the treatment today but then the NP showed up and we did some other residents first. LN 33 again stated the resident looked like she was in pain during the treatment. LN 33 stated, I will tell the nurse to consider using a stronger pain medicine. I know there is one available. A record review was conducted on 10/30/19. The record indicated no stronger pain medicine was given 555206 Page 23 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0697 to Resident 49 on 10/29/19. Level of Harm - Minimal harm or potential for actual harm On 10/30/19 at 9:01 A.M., an interview was conducted with RNA 3. RNA 3 stated he did ROM on Resident 49. RNA 3 stated, We try to tell nurses when we are going to do ROM. It's up to them to give pain meds if they want. Residents Affected - Few On 10/30/19 at 11:10 A.M., a joint observation of Resident 49's ROM treatment, and interview with RNA 34 was conducted. Resident 49 grimaced and moaned in pain as RNA 34 performed ROM movements on both the upper body and lower body. RNA 34 stated she told the nurse if the resident was in pain. On 10/30/19 at 11:25 A.M., a joint interview and record review was conducted with LN 42. LN 42 stated communication was a problem in that she does not always hear when a resident was in pain. LN 42 stated, The treatment nurse and the RNA don't always tell me. LN 42 acknowledged none of the PRN pain medications had been given to Resident 49 during the months of September or October. On 10/31/19 at 9:48 A.M., an interview was conducted with the DON. The DON acknowledged there was a communication problem and Resident 49 may have been in unnecessary pain. Per the facility's policy titled, Pain Assessment and Management, revised March 2015, .Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .review the resident's treatment record or recent nurses' notes to identify any situation or interventions where an increase in the resident's pain may be anticipated .implement the medication regimen as ordered . 555206 Page 24 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure the narcotic count inventory sheet (CDR) reflected the medications administered to residents as documented on the Medication Administration Record (MAR), for one of two residents (20) reviewed for medication storage. This deficient practice had the potential to cause the facility to not be able to readily identify loss and drug diversion (illegal distribution or abuse of prescription drugs as their use for unintended purposes) of controlled medication. Findings: On 10/29/19 at 10:41 A.M., an observation and interview was conducted with LN 1 during inspection of medication cart #2, located at Station One. A random narcotic bubble pack card (a method of packaging medications, where each dose is enclosed in a clear plastic bubble, on a cardboard sheet) was removed for inspection. The narcotic bubble back was assigned to Resident 110, and labeled Percocet 10-325 milligrams tablets. LN 1 stated 36 tablets remained sealed in the bubble pack card. On 10/29/19 at 11:23 A.M., Resident 110's CDR for October 2019, was compared to the October 2019 MAR. Four of the 21 entries on Resident 110's CDR, were not documented on the MAR. On 10/30/19 at 8:57 A.M., an interview was conducted with LN 2. LN 2 stated the CDR and MAR always needed to be identical for accountability of narcotic medications. LN 2 stated if a CDR and MAR did not match, a narcotic could be given more frequently than it was intended and the resident might be over-medicated. On 10/30/19 at 9:05 A.M., an interview was conducted with the DON. The DON stated CDR's and MAR's needed to be identical for clarification of the administration and to verify the medication was actually administered and not diverted. The facility could not provide a policy for the documentation of narcotics administeredrelated on the CDR and MAR. 555206 Page 25 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN (as needed) psychotropic (mind altering) medications were limited to 14 days (unless documentation of a physician's order to extend the medication), for one of five residents (15) reviewed for unnecessary medications. This failure put Resident 15 at risk for complications resulting from potentially unnecessary medications. Findings: Resident 15 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) with behavioral disturbances, per the facility's admission record. On 10/31/19, Resident 15's clinical record was reviewed. The physician order, dated 8/3/19, indicated, Lorazepam (antipsychotic medication used to treat anxiety) be administered as needed for anxiety. The physician's order included behavior monitoring every shift, for episodes of agitation manifested by chasing and hitting staff. Resident 15's MAR was reviewed from 8/3/19 through 10/31/19. Lorazepam was administered three times, with documented behaviors twice. The physician progress notes contained no rationale for the continued use of prn Lorazepam, pass the 14-day limit. On 10/31/19 at 9:55 A.M., an interview and record review was conducted with the QAN. The QAN stated she was responsible for conducting bi-monthly psychotropic committee reviews for all residents receiving psychotropic medications. The QAN stated prn mediations had a 14-day limit and then the medication needed to be re-evaluated to determine the necessity of the medication. The QAN stated if a physician or nurse practitioner, wanted to continue the prn medication, a rationale was required to be documented in the physician progress notes. The QAN stated when determining the necessity of the medication, physician's reviewed the number of behaviors documented and determine if the benefits outweighed the risks. The QAN reviewed Resident 15's MAR from 8/3/19 through 10/31/19, to compare behavior frequency with how often the medication was administered. The QAN stated the prn medication review was missed by the psychotropic review committee and the medication should have been stopped after 14 days. The QAN stated Resident 15's physician never documented a rationale for the continued use and there was never a stop date when the medication was initially ordered. The QAN stated this error should have been caught by her or the committee during their bi-monthly review, and it was missed. On 10/31/19 at 12:31 P.M., an interview was conducted with the DON. The DON stated she expected behaviors to be documented when staff were administering a prn psychotropic medication. The DON stated 555206 Page 26 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0758 prn medications should not extend the 14-day limited unless the physician documented the necessity. Level of Harm - Minimal harm or potential for actual harm Per the facility's policy, titled Antipsychotropic Medication Use, dated December 2016, . 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Residents Affected - Few 555206 Page 27 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to secure medications when: 1. Medications were left unattended at the beside for one of 31 sampled residents (20); and 2. One of three treatment carts was left unlocked and unattended. These failures had the potential for staff, residents, or visitors to have access to medication not attended for them. 1. On 10/28/19 at 8:19 A.M., an observation and interview was conducted with Resident 20. Resident 20 was sitting up in bed, eating breakfast. A small clear medication cup was on the bedside table, which contained a small oval yellow pill and a small oval pink pill. Resident 20 stated she was supposed to take the pills. No staff were in the room and a medication cart was not visible outside the resident's room. On 10/28/19 at 8:22 A.M., LN 3 was observed entering Resident 20's room. On 10/28/19 at 8:24 A.M., a subsequent observation and interview was conducted with Resident 20. Resident 20 was sitting up in bed and her breakfast tray was gone. The clear plastic medication cup was gone from the bedside table. Resident 20 stated she swallowed her pills. On 10/28/19 at 9:57 A.M., an interview was conducted with LN 3. LN 3 stated she went into Resident 20's room to check on her and noticed medications were left unattended at the bedside. LN 3 stated medication should never be left unattended, because you could not be sure if the resident took the medication. On 10/30/19 at 8:57 A.M., an interview was conducted with LN 2. LN 2 stated medication should never be left unattended, especially at the bedside. LN 2 stated a confused resident could wander into that room and accidentally take the medication, which could be harmful. On 10/30/19 at 9:05 A.M., an interview was conducted with the DON. The DON stated the medication nurse should always watch resident's taking their medication and it should never be left unattended at a bedside. Per the facility's policy, titled Administering Medications, dated December 2012, . 17.Medications will not be left at the resident's bedside . 2. On 10/30/19 at 9:28 A.M., an observation was conducted near room [ROOM NUMBER]. A treatment cart was left unlocked and out of view from the nurses' station. One resident was sitting in a wheelchair across the hall from the treatment cart. The second drawer was observed to have contained an estimated 15-18 tubes of prescription ointments and creams. On 10/30/19 at 9:28 A.M., the ADON approached and stated treatment carts should never be left unlocked and unattended. The ADON stated leaving a cart unlocked, could cause harm, because anyone could 555206 Page 28 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0761 have access to medications stored inside. Level of Harm - Minimal harm or potential for actual harm On 10/31/19 at 12:31 P.M., an interview was conducted with the DON. The DON stated treatment carts should always be kept locked when not in use, because anyone passing by could have access to medications. Residents Affected - Few Per the facility policy, titled Storage of Medications, dated April 2019, . 1. Drugs and biologicals used in the facility are stored in locked compartments . 9. Unlocked medications carts are not left unattended . 555206 Page 29 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (65), reviewed for dental needs, was provided dental services to meet the resident's needs. Residents Affected - Few This deficient practice had a potential for Resident 65 to experience difficulty chewing and weight loss, due to not having any teeth or dentures. Findings: Resident 65 was admitted on [DATE], with diagnoses which included difficulty walking and lack of coordination, per the facility's admission Record. On 10/28/19 at 8:54 A.M., an observation and interview was conducted with Resident 65, while he sat in a wheel chair beside his bed. Resident 65 had no teeth or dentures in his mouth. A partially consumed breakfast tray sat on a near-by table. Resident 65 stated he had been without teeth for over a year. Resident 65 stated when he arrived, they said they would try to get him dentures. Resident 65 stated he had not seen a dentist since he arrived. On 10/30/19, a record review was conducted for Resident 65: Resident 65's admission MDS (an assessment tool) dated 9/7/19, indicated Resident 65 had a BIMS (a cognitive assessment) score of 13, (score 13-15, indicates cognitively intact). The facility's admission Assessment, dated 8/31/19, indicated Resident 65 had no teeth or dentures, and his dentures were previously lost. The facility's admission Baseline Care Plan, dated 8/31/19, indicated Resident 65 was edentulous (without teeth), on a controlled carbohydrate diet, and there were dietary risk of weight loss and chewing problems. No goals or interventions were listed. The facility's Care Plan Conference Review, dated 9/2/19, indicating Resident 65 was edentulous and he did not have dentures. The facility's Social Services Assessment-Discharge Planning, dated 9/5/19, indicating Resident 65 had no issues related to dental issues or needs. On 10/30/19 at 8:23 A.M., an interview was conducted with CNA 1. CNA 1 stated if a resident requested dental services, it would verbally reported to the charge nurse. CNA 1 stated the charge nurse would then report it to the SSD, so the SSD could schedule a dental exam. On 10/30/19 at 8:25 A.M., an interview was conducted with the CN. The CN stated if a resident had dental issues or requested to see a dentist, it should be documented in a nurse's progress note. The CN stated she would also verbally inform the SSD or send a note to the SSD in a next day communication document. On 10/30/19 at 8:29 A.M., an interview and record review was conducted with the SSD. The SSD stated she received dental request from staff via the home page in their computer documentation system. 555206 Page 30 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The SSD stated she would also ask residents about their dental needs during a care conference. The SSD stated she would make a dental referral and add the resident's name to a monthly dental exam list. The SSD stated the dentist came to the facility once a month to perform dental exams for residents on the dental list. The SSDs monthly dental referral lists were reviewed. Resident 65 was not on the dental list for September or October 2019. The SSD stated Resident 65 had a care conference performed on 9/2/19 with the CM and a social service assessment on 9/5/19 by the SSA. On 10/30/19 at 8:45 A.M., an interview was conducted with the SSA. The SSA stated she interviewed Resident 65 and completed the social service assessment on 9/3/19. The SSA stated she did not inquire if Resident 65 had or needed dentures. The SSA stated she did not adequately assess Resident 65's dental needs if she documented nothing noted. The SSA stated she did not make a referral for a dental examine since Resident 65's name could not be located on the monthly dental examine list. On 10/30/19 at 8:50 A.M., an interview was conducted with the CM. The CM stated during the 9/2/19 care conference, Resident 65 was identified as having no dentures. The CM stated she should have put Resident 65 on the dental referral list for evaluation, and she did not. On 10/30/19 at 9:36 A.M., an interview was conducted with the DON. The DON stated Resident 65 did not receive a thorough assessment of his dental needs and a dental referral should have been made. According to the facility's policy, titled Dental Services, dated December 2016, Routine and emergency dental services are available to meet the resident's oral health services in 555206 Page 31 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0803 Level of Harm - Minimal harm or potential for actual 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. Based on observation, interview, and record review, the facility failed to follow the pureed recipe for fried rice for 22 of 22 residents reviewed for pureed diet. Residents Affected - Some As a result, the nutrition of the pureed diets was compromised potentially affecting residents' health. Findings: On 10/28/19, the weekly menu was obtained from the facility. The menu for 10/29/19 was listed with the following starch: Fried Rice. On 10/29/19 at 11:40 A.M., the pureed starch had already been prepared, and was on the tray line for plating. The pureed fried rice appeared to be a bright white color. The regular fried rice appeared brownish with green peas. Near the end of tray line, a test tray ( a sample tray) was requested for both a regular diet and a pureed diet. After the final tray was served to a resident in unit 3, the test tray was removed from the transport cart. The RD 1, DNS, and this writer sampled the starch on the sample tray. The pureed starch had a thick white appearance and did not have the same flavor as the fried rice from the regular diet. On 10/29/19 at 1:55 P.M., an interview with CK 1 and CK 2 was conducted. CK 1 and CK 2 stated they prepared the meal together. CK 1 and CK 2 stated they did not puree the fried rice per the recipe, instead they used creamy white rice in place of the fried rice. On 10/29/19 at 2 P.M., an interview with the DNS was conducted. The DNS stated the pureed menu was supposed to be the same as the regular menu, except the pureed texture. DNS stated, We use the spreadsheet to make the menu, the pureed and regular should be the same diet. The ingredients on the spreadsheet for fried rice were brown rice, peas, eggs, and onions. When the fried rice nutrient value and calorie value were compared, the fried rice had 177 calories per serving, with 4.9 grams of protein, and 29 grams of carbohydrate. The cream of rice (per the box name) white rice had 160 calories, 2 grams of protein, and 36 grams of carbohydrate. On 10/29/19 at 2:10 P.M., an interview with the DNS was conducted. The DNS stated creamy rice and fried rice were not the same, and we are supposed to follow the recipes. RD 1 was not available on 10/30/19 or 10/31/19 for interview. The facility could not provide a policy regarding following kitchen menus. 555206 Page 32 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility did not follow the recipe for pureed fried rice or for pureed carrots for 22 of 22 residents reviewed for pureed diet. Residents Affected - Some As a result, 22 residents were served rice which was bland and carrots which were not seasoned per the recipes. Findings: On 10/28/19, the weekly menu was obtained from the facility. The lunch menu for 10/29/19 was listed with the following starch: Fried Rice. On 10/29/19 at 11:40 A.M., the pureed starch had already been prepared, and was on the tray line for plating. The pureed fried rice appeared to be a bright white color. The fried rice appeared brownish with green peas. Near the end of tray line, a test tray (a sample tray) was requested for both a regular diet and a pureed diet. After the final tray was served to a resident in unit 3, the test tray was removed from the transport cart. RD 1, DNS, and this writer sampled the starch from the test tray. The pureed starch had a thick white appearance and did not have the same flavor as the fried rice from the sampled regular diet. RD 1 and the DNS stated the pureed rice and regular rice did not taste the same. RD 1 and the DNS stated the pureed rice lacked flavor and the pureed carrots were not seasoned the same as the regular carrots. On 10/29/19 at 1:55 P.M., an interview with CK 1 and CK 2 was conducted. CK 1 and CK 2 stated they prepared the meal together. CK 1 and CK 2 stated they did not puree the fried rice per the recipe, instead they used creamy white rice, with no seasoning, in place of the fried rice. CK 1 and CK 2 stated they did not put any parsley seasoning in the pureed carrots, even though the recipe required parsley. The fried rice ingredient spreadsheet instructions were brown rice, peas, eggs, salt, oil, onions, and lite soy sauce. The carrot ingredient spreadsheet instructions were carrots, margarine, salt, and chopped parsley. On 10/29/19 at 2 P.M., an interview with the DNS was conducted. The DNS stated the pureed menu was supposed to be the same as the regular menu, except the pureed texture. The DNS stated, We use the spreadsheet to make the menu, the pureed and regular should be the same diet. The facility could not provide a policy regarding following diet menus. 555206 Page 33 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure food safety requirements were followed when: Residents Affected - Few 1. Dented cans were not removed from stock, 2. Juices were not labeled or dated and, 3. Staff did not wear a beard restraint in the kitchen. As a result, residents were subject to bacterial illness and foodborne illnesses from dented cans, undated juices, and potential hair falling into residents' food. Findings: 1. On 10/28/19 at 7:50 A.M., the dry storage area of the kitchen was inspected. One can of peaches had an indentation in the middle of the can. One can of tuna had two accordion dents in the can. On 10/28/19 at 7:51 A.M., an interview with the DNS was conducted. The DNS stated all dented cans must be removed and placed in the bin for return to the supplier. Per the facility policy, Food Storage-Dented Cans, dated 2018, .All dented cans (defined as side seam or or rim dents) and rusty can are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund . 2. On 10/29/19 at 8:10 A.M., a joint observation of the resident refrigerator in Nursing station 1 and interview with the DON was conducted. Three, four ounce cartons of orange juice and one, four ounce carton of pineapple juice were undated and unlabeled. The DON stated these juices were supplied by the kitchen. The DON confirmed there was no date on the five juices. The DON stated everything needed to be dated and labeled. A sign on the front of the refrigerator was as follows: Resident Refrigerator Date and Label any refrigerator items Any resident items will be disposed of it [sic] the following is not met: No date or label Older than 3 days 3. During an observation in the kitchen on 10/28/19 at 3:07 P.M., DA 1 wore a beard restraint around his neck. The beard guard did not cover any part of his face, only the front of his neck where 555206 Page 34 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0812 there was no hair growth. Level of Harm - Minimal harm or potential for actual harm On 10/28/19 at 3:08 P.M., an interview with DA 1 was conducted. DA 1 stated, he was supposed to wear the beard guard all the time when he was in the kitchen but he had removed it from his face and his beard was not covered. Residents Affected - Few Per the facility policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, dated October 2017, .10. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. 555206 Page 35 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure CNA 31 had a current professional license. Residents Affected - Few This failure created the potential for the facility to be unaware of an active disciplinary action against CNA 31. Findings: On [DATE], a record review was conducted of CNA 31's employee file. CNA 31's date of hire with the facility was [DATE]. The California Department of Public Health L&C (Licensing and Certification) Verification Detail Page, dated [DATE], indicated CNA 31's license was effective on [DATE], had a criminal record clearance, and CNA 31 was deemed employable. The Verification Detail page indicated CNA 31's license expired on [DATE]. A review of the Daily Staffing Assignments which included the employee's sign in with signatures that indicated CNA 31 had signed in and worked 19 shifts since [DATE]. On [DATE] at 11:38 A.M., a joint interview was conducted with the ADM and the DSD. The ADM confirmed CNA 31 was employed by the facility and was working shifts. The ADM acknowledged CNA 31's license was expired. The DSD stated license status was reviewed periodically but it was ultimately the staff member's responsibility to apply for a timely license renewal.The ADM stated CNA 31 would be suspended from working until her license was renewed. Per the State of California Health and Safety Code, Division 2, Chapter 2, Health Facilities, Article 9, titled Training Programs in Skilled Nursing and Intermediate Care Facilities, .requirement that certified nurse assistants obtain a criminal record clearance upon certification and biannually thereafter . The facility did not provide a policy related to CNA license renewal. 555206 Page 36 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document two of two residents reviewed for resident documentation when: 1. Resident 77's toenail treatment was documented as being performed according to the physician's order; and, 2. Resident 429's did not have an accurate fall assessment completed, after a recent fall. As a result, Resident 77 and Resident 429 were at risk of not receiving the appropriate care and treatment. Findings: 1. Resident 77 was admitted to the facility on [DATE], per the facility's admission Records. On 10/28/19 at 10:27 A.M., an interview was conducted with Resident 77, while he laid in bed. Resident 77 stated a podiatrist (foot doctor) came to see him last week for a toe issue. Resident 77 stated the podiatrist ordered a treatment, saying he needed to soak the toe every other day, or else he would lose his toenail, due to an infection. Resident 77 stated the staff had not yet soaked his toe and he was afraid his toe infection would get worse. On 10/29/19, Resident 77's clinical record was reviewed. The physician's order, dated 10/24/19, indicated. Soak Right great toe in warm water with Epsom salts for ten minutes, pat dry, apply triple ointment cover with Band-Aid. One time a day every Mon. Wed. Fri. for ingrown toenail for two weeks, Start 10/25/19. On 10/30/19 a subsequent interview was conducted with Resident 77. Resident 77 stated staff soaked his toe for the first time today. On 10/31/19, Resident 77's Treatment Administration Record (TAR) was review. The TAR had LN initials for toenail treatments provided on 10/25/19 and 10/28/19. On 10/31/19 at 11:27 A.M., an interview and record review was conducted with LN 3. LN 3 confirmed she performed the toenail treatments for Resident 77 on 10/25/19 and 10/28/19. LN 3 stated on 10/25/19, the facility did not have Epsom salt, so she cleaned the toenail area with normal saline. LN 3 stated on 10/28/19, the soaking salt had arrived, but the resident was sleeping when she went in the room. LN 3 stated she endorsed the treatment to the next shift, and she signed off the TAR, as if she had done the treatment. LN 3 stated she should not have documented the treatment as being performed, when it was not. LN 3 stated if the endorsed shift did not do the treatment as she asked, then Resident 77 missed a treatment. On 10/31/19 at 12:51 P.M., an interview was conducted with the DON. The DON stated resident 77's nail treatment should have been performed as ordered by the physician. The DON stated the resident had a delay in treatment and his toe infection could have worsened. 555206 Page 37 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0842 Level of Harm - Minimal harm or potential for actual harm Per the facility's policy, titled Medication Orders, dated November 2014, .Recording Orders . 6. Treatment Orders-When recording treatment orders, specify the treatment, frequency and duration of the treatment. Per the facility's policy, titled Charting and Documentation, dated July 2017, . 3. Documentation in the medical record .will be complete and accurate . Residents Affected - Few 2. A review of the clinical record for Resident 429 was conducted. The admission Record, dated 10/10/19, indicated Resident 429 was admitted to the facility with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement), Alzheimer's disease (a disease that destroys memory and other mental function), and a history of repeated falls. A review of the clinical record for Resident 429 was conducted on 10/29/19. Resident 429's record contained a progress note, dated 10/20/19 at 10:53 A.M. LN 13 documented in the progress note that Resident 429 had sustained an unwitnessed fall. During this clinical record review, Resident 429 was noted to have two fall risk assessments documented. One was documented on the date of Resident 429's admission, 10/10/19. Per this fall risk assessment, Resident 429 had score of 21, which meant he was at a high risk for falls level. The second fall risk assessment was documented on 10/20/19, following his unwitnessed fall. This fall risk assessment gave Resident 429 a fall risk score of 9, which did not put him at a high risk for falls level. This second fall risk assessment was completed by LN 13. The second fall risk assessment documented Resident 439 had no history of falls. In addition, it did not record any of the gait/balance challenges Resident 439 dealt with. A joint interview and record review with the ADON was conducted on 10/31/19 at 9:46 A.M. The ADON stated the expectation is that fall risk assessments of residents should be accurate. The ADON stated that based on his history, the fall risk score for Resident 429 dated 10/20/19 was not accurately documented. A joint interview and record review with LN 13 was conducted on 10/31/19 at 11:18 A.M. LN 13 stated she had only worked in the facility for about one month. She stated she was new to working in a SNF (skilled nursing facility). She stated she had made mistakes while documenting Resident 429's fall risk assessment. LN 13 stated she had not been trained at all to fill out the assessment. She stated, It was my first time doing one. LN 13 went on to say that it is important for residents to have accurate fall risk assessments documented, because care of the resident is based on these evaluations. An interview with the DON was conducted on 10/31/19 at 12:45 P.M. The DON stated documentation should be accurate and that all nurses should be trained to document assessments correctly prior to doing them. According to the facility's policy, titled Charting and Documentation and revised July 2017: .3. Documentation in the medical record will be .complete and accurate . 555206 Page 38 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure infection control practices were followed when: Residents Affected - Few 1. Hand hygiene was not performed by 2 of 6 CNAs ( CNA 8, CNA 35) during a meal service when passing meal trays to residents in the dining room and, 2. A CPAP mask (continuous positive air pressure - provides air pressure to keep lung airways open) was left lying on the bedside table open to potential infection for one of two residents reviewed for respiratory care (62). As a result, there was a potential to transmit infectious agents between residents during food service and the potential for the CPAP mask to pick up germs from the bedside table potentially causing Resident 62 to become sick when using the mask. Findings: 1. On 10/28/19 at 12 P.M., a lunch observation was conducted in the residents' dining room. There was one hand wash sink and only one bottle of hand sanitizer observed in the dining room, during the meal service. The one bottle of hand sanitizer observed was on the soup/coffee cart table. Six staff members passed trays to residents from the meal carts, to the tables for each resident. On 10/28/19 at 12:13 P.M., CNA 8 served a tray to the first resident, opened the food packages on the tray, and touched the resident's utensils. CNA 8 did not wash or sanitize his hands. CNA 8 then served a tray to a second resident. CNA 8 followed the same procedure when he opened the food packages, and touched the resident's utensils. CNA 8 did not wash or sanitize his hands after he served the second tray. CNA 8 scratched his head with his hand, and did not wash or sanitize his hands. CNA 8 served a third tray to a different resident. CNA 8 followed the same procedure when he opened the food packages, and touched the resident's utensils. While CNA 8 waited for the next food cart to arrive, he touched a resident, then moved a different resident in a wheelchair up to the table. CNA 8 did not wash or sanitize his hands. CNA 8 served additional two food trays, removed dirty dishes, and was not observed to wash his hands. On 10/28/19 at 12:18 P.M., an observation of CNA 35 was conducted in the dining room. CNA 35 did not sanitize her hands after she removed the the clothing protector from a resident at table 7. On 10/28/19 at 12:19 P.M., an interview with the CM was conducted. The CM stated we must sanitize our hands after we take off dirty clothing protectors. The CM further stated we should sanitize our hands before we touch a resident and after we touch a resident. 555206 Page 39 of 40 555206 10/31/2019 Boulder Creek Post Acute 12696 Monte Vista Road Poway, CA 92064

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/28/19 at 12:21 P.M., an observation of staff and an interview with the CM was conducted in the dining room. Five staff members were in a line in front of the dining room sink while they waited to wash their hands. The CM stated, We used to have sanitizers on the wall, but they were never working. On 10/31/19 at 1:20 P.M., an interview with RD 2 was conducted. RD 2 stated she expected good hand hygiene when food was delivered. On 10/31/19 at 1:28 P.M., an interview with CNA 8 was conducted. CNA 8 stated he had been a staff member for 8 years. CNA 8 stated he was not supposed to touch his hair when he served food. CNA 8 stated hand hygiene was important for infection control. CNA 8 stated he usually washed his hands after every third tray, if he did not touch the food or the residents. Per the facility policy titled, Handwashing/Hand Hygiene, revised August 2015, .6. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situation: .b. Before and after direct contact with resident; .p. Before and after assisting a resident with meal . 2. Resident 62 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by shortness of breath, wheezing, or a chronic cough), and need for supplemental oxygen per the facility's admission Record. Resident 62's clinical record was reviewed on 10/31/19. The Order Summary Report, dated 10/31/19, indicated an order was initiated on 5/27/19 for LN to ensure CPAP on .at bedtime. On 10/28/19 at 8:30 A.M., an observation was made of Resident 62's CPAP apparatus. The face mask used by Resident 62 to obtain positive pressure airflow was lying on the bedside table with the portion of the mask that touches the face in contact with the table. On 10/28/19 at 8:35 A.M., a joint observation and interview was conducted with LN 31. LN 31 confirmed the mask was left lying on the table and should have been put in the protective plastic bag hanging on the CPAP device when not in use. LN 31 stated it was an infection control issue. On 10/28/19 at 8:55 A.M., an interview was conducted with the DON. The DON acknowledged the CPAP mask should have been put in a protective bag when not in use, and could potentially cause an infection. The facility was unable to provide a policy on CPAP mask storage. 555206 Page 40 of 40

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

21 citations recorded^*CMS

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.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0688GeneralS&S Dpotential for harm
F688 - Mobility
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.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0839GeneralS&S Dpotential for harm
F839 - Staff qualifications
Employ staff that are licensed, certified, or registered in accordance with state laws.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0790GeneralS&S Dpotential for harm
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.

FAQ · About this visit

Common questions about this visit

What happened during the October 31, 2019 survey of BOULDER CREEK POST ACUTE?

This was a inspection survey of BOULDER CREEK POST ACUTE on October 31, 2019. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BOULDER CREEK POST ACUTE on October 31, 2019?

Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 31, 2019