Inspection visit
Health inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dignity and respect was provided for two of two sampled residents ( 50 &110) when staff was standing over, while assisting and feeding the residents (50 &110). This failure had the potential to affect the resident's self-esteem, self-worth, and quality of care.
Findings: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included dysphasia (difficulty swallowing), per the facility's admission Record. On 5/18/22 at 12:35 P.M., a lunch observation was conducted in front of Resident 50's room. Resident 50 was observed sitting in a wheelchair in the room. Certified Nursing Assistant (CNA) 30 was standing over while assisting and feeding Resident 50. On 5/18/22 at 12:40 P.M., an interview with CNA 30 was conducted. CNA 30 stated she was standing over while feeding Resident 50 because there was no chair in the room. She stated the expectation was to sit while assisting the residents with meals. 2. Resident 110 was admitted to the facility on [DATE] with diagnoses which included dysphasia (difficulty swallowing), per the facility's admission Record. On 5/19/22 at 8:06 A.M., a breakfast observation was conducted in front of Resident 110's room. Resident 110 was observed lying in bed with head of the bed elevated. CNA 31 was standing over while assisting and feeding Resident 110. On 5/19/22 at 8:22 A.M., an interview with CNA 31 was conducted. CNA 31 stated her expectation was to bring a chair to sit and assist the resident with meals. On 5/19/22 at 10:14 A.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated it was important for the CNAs to sit and assist the residents with meals. His expectation was the CNAs to be at eye level with the residents while assisting with meals. On 5/20/22 at 9:20 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the CNAs should have sat down while assisting and feeding the residents because it was an
Page 1 of 23
555206
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0550
dignity issue.
Level of Harm - Minimal harm or potential for actual harm
According to the facility's policy titled, Assistance with Meals, revised July 2017, .3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: 1. Not standing over residents while assisting them with meals .
Residents Affected - Few
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Page 2 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 5/19/22 at 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch.
Residents Affected - Few On. 5/19/22 at 3:29 P.M., the DON was interviewed. The DON stated Resident 54's mittens were assessed and determine not to be a restraint and the responsible party had given consent. After a review of the record, the DON admitted Resident 54's responsible party did not sign the informed consent. According to the facility's policy titled, Informed Consent revised 2021, .It is the policy of this facility that the resident has the right to be fully informed by a physician of his or her total health status and to be 3. the facility will verify that the resident or their authorized representative has given informed consent .5. The facility will verify informed consent prior to the administration of psychotherapeutic drug .
Based on interview and record review, the facility failed to obtain informed consent from a physician prior to administering psychotropic medications (a medication which affects the mind) and did not obtain a consent from responsible party prior to applying restraints (a measure that keeps resident within limits) for two of two sampled residents (126 & 54 ). As a result, the residents may not have been fully informed of the risks and benefits of the psychotropic medications and restraints.
Findings: 1. Resident 126 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder (mental health disorder) and anxiety (a mental disorder characterized by excessive worrisome), per the facility's admission Record. Per facility's Physician Order, the physician wrote an order for Resident 126 for venlafaxine (medication for depression) for depression and lorazepam (medication for anxiety) for anxiety. On 5/19/22 at 3:43 P.M., a concurrent interview and record review with LN 31 was conducted. The informed consent for venlafaxine and lorazepam did not have a date, physician and resident's signatures. LN 31 stated two nurses verbally obtained the informed consents for venlafaxine and lorazepam from Resident 126. On 5/20/22 at 9:23 A.M., an interview with the DON was conducted. The DON stated the physicians were responsible for obtaining the informed consent. The DON stated the Resident 126's informed consents for lorazepam and venlafaxine were not acceptable, and she expected the nurses to only verify if the physician obtained the consents or not.
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Page 3 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to allow the resident council to meet without staff. As a result, the residents were not able have a confidential meeting.
Residents Affected - Some Finding: On 5/18/22 at 10:30 A.M., a resident council meeting was held. During the meeting, a majority consensus of confidential residents attending stated that they could not meet without a staff member present. Residents stated Activity Director (AD) insisted to attend all meetings. On 5/18/22 at 12:04 P.M., an interview was conducted with the Activity Director (AD). The AD stated that she needed to attend resident council meetings to take the meeting minutes. She stated that a staff present at the meeting might make the residents uncomfortable with expressing their concerns openly. The AD's expectation was that the residents had the right to run the meeting themselves without staff present. On 5/20/22 at 2:28 P.M., an interview with the ADM was conducted. ADM stated that staff present at all the meetings could make the residents uncomfortable speaking honestly about the facility. He stated the expectation should be that the residents should be able to meet without staff, and staff would have to be invited to meetings by the council president and other members.
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Page 4 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0584
Level of Harm - Minimal harm or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Based on observation, interview, and record review the facility failed to provide a homelike environment for two of two sampled residents (63& 90).
Residents Affected - Few As a result the residents did not feel comfortable in their room.
Findings: On 5/17/22 at 12:58 P.M., a concurrent interview and observation of Resident 90 in his room was conducted. Resident 90 stated that the NOC shift staff often threw dirty linen and diapers on the floor when cleaning them. Grime and dirt were noted around the floor at the edges of the bed, by bed wheels and also by the residents' drawers. It was noted that the walls had torn drywall and scraped paint in many areas behind his bed. Resident 90 stated that the wall had been damaged by the bed and mechanical lift (resident lifting device) going into the wall. He stated he had not seen anyone clean the room in a while. On 5/17/22 at 2 P.M., a concurrent interview and observation of Resident 63 in his room was conducted. Resident 63 was Resident 90's roommate. Resident 63 stated the only problem he had with the facility was that his room was dirty and there was often feces on the floor. A smeared brown material was observed in the middle of Resident 63's floor. On 5/17/22 at 2:25P.M., a concurrent observation and interview with the Infection Preventionist, ( IP) was conducted. IP inspected the smeared brown material on Resident 63's floor. She stated that the expectation was that feces should be cleaned off the floor as soon as it was seen by staff. She stated that by not cleaning the floors, there could be a spread of infection. On 5/18/22 at 8:30 A.M., a followup observation of Resident 63 and 90's room was conducted. The room was observed to have been spot cleaned, the smeared brown material had been removed, however nothing else had been addressed. On 5/19/22 at 9:45 A.M., a concurrent interview and observation of Resident 63 and 90's room was conducted with the Maintenance Supervisor (MS). MS stated that they had just stopped using their cleaning vendor on 5/15/22 and assumed responsibility for cleaning, laundry, and linen on 5/16/22. He stated he did not know about the condition of the room; he had not been able to make rounds on the rooms since taking over the cleaning services. He stated the grime and disrepair were not homelike for the residents. His expectation was that every room would be cleaned once a day. A record review of facility's police titled, Quality of Life-Homelike Environment was conducted. This policy indicated, .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment .
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Page 5 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0585
Level of Harm - Minimal harm or potential for actual harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Based on observation, interview and record review, the facility failed to inform the residents and staff on how to file a grievance.
Residents Affected - Some As a result, residents were not able to exercise their rights to file a grievance.
Findings: On 5/18/22 at 10:30 A.M., a resident council meeting was conducted. The following statements about grievances were made: 1. The majority of residents attending stated that they did not know how to file a grievance or were unable to file a grievance. 2. CR 1 stated that they could not get a grievance form when she asked the nurses for one. She went to every nurses' station and was unable to get a form. She wrote a grievance on a blank sheet of paper and handed that to the staff, but she was afraid that the staff would read her paper. 3. CR 2 stated that they were afraid of speaking up or writing a grievance out of fear of retribution by the facility. 4. CR 3 stated they thought the Social Services director was too busy to respond to grievances, so they didn't bother writing them. 5. CR 4 stated that they had made grievances but had never received rationale back after it was filed. On 5/20/22 at 10:13 A.M., a follow-up interview with CR 1 was conducted. She stated that she had checked in at every nurses' station and the nurses were unable to find the grievance form. Instead, she wrote her grievance on blank piece of paper, but she felt some remorse doing this, as she felt it lacked confidentiality. She stated that they were able to resolve the grievance once it reached Social Services, but the whole process was intimidating. On 5/20/22 at 10:20 A.M., a concurrent interview, observation and record review was conducted with LN 1 . LN 1 stated that she was unable to find the grievance forms in nursing station 2. On 5/20/22 at 10:24 A.M., a concurrent interview, observation and record review with LN 2 was
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Page 6 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0585
Level of Harm - Minimal harm or potential for actual harm
conducted. LN 2 stated that she was unable to find the forms in nursing station 3. She stated she was unsure where to find the grievance forms. On 5/20/22 at 10:40 A.M., a concurrent interview, observation and record review with LN 30 was conducted. LN 30 stated that she was unable to find the grievance forms in nursing station 1.
Residents Affected - Some On 5/20/22 at 10:53 A.M., a concurrent interview, observation and record review with the Social Services Director (SSD) was conducted. She stated the current process was not working, and staff needed in-servicing. On 5/20/22 at 2:28 P.M., an interview with the ADM was conducted. ADM stated that not having the grievance forms readily available for residents might prevent them from filing grievances. He stated that the expectation for the future would to be educate the residents and staff about filing grievances. A record review of the facility policy titled, Grievances/Complaint, Filing, dated 4/2017, was conducted. This policy indicated, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances(e.g. the State Ombudsman).
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Page 7 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm or potential for actual harm
Based on observation interview and record review, the facility failed to ensure one of 26 sampled residents (54) was free from restraints that the restraint was the least restrictive, used for the least amount of time, and was re-evaluated when they repeatedly applied mittens to both hands.
Residents Affected - Few As a result, resident 54 was subject to an unnecessary restraint.
Findings: On 5/19/22, at 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22, there was a note from the dermatologist dated 4/27/22, to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens. The care plan only directed staff to monitor every shift for breakdown and placement. There was no care plan or assessment or consent or orders found in the record for the mittens as a restraint. On 5/19/22 at 3:04 P.M., the MDS Coordinator was interviewed. The MDS coordinator stated the mittens were not a restraint, and they were to stop him from scratching. There was an order from the dermatologist to apply mittens to both hands to prevent scratching. The MDS coordinator felt the mittens were for safety, not a restraint. The mittens were not coded on the MDS as a restraint or for safety. The MDS coordinator stated Resident 54's Responsible Party had signed consent for the mittens. On 5/19/22 at 3:29 P.M., the DON was interviewed. The DON stated Resident 54's mittens were assessed and determine not to be a restraint and the responsible party had given consent. After a review of the record, the DON admitted there was no assessment for the mittens as a restraint or safety device. And there was no informed consent for the mitten signed by Resident 54's responsible party.
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Page 8 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0636
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Based on observation interview and record review, the facility failed to ensure one of 26 sampled residents (54) was free from restraints. In addition, the facility did not ensure a resident's restraint was least restricted alternative for the least amount of time and re-evaluated, when they repeatedly applied mittens to both hands. As a result, resident 54 was subject to an unnecessary restraint.
Findings: On 5/19/22, At 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22, there was a note from the dermatologist dated 4/27/22 to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens the care plan only directed staff to monitor every shift for breakdown and placement. There was no care plan or assessment or consent or orders found in the record for the mittens as a restraint. On 5/19/22 at 3:04 P.M., the MDS Coordinator was interviewed. The MD's coordinator stated the mittens are not a restraint they were to stop him from scratching, there was an order from the dermatologist. Apply mittens to both hands to prevent scratching. The MDS coordinator felt the mittens were for safety, not a restraint. The mittens were not coded on the MDS as a restraint of for safety. The MDS coordinator stated Resident 54's Responsible Party had signed consent for the mittens. On 5/19/22 at 3:29 P.M., the DON was interviewed. The DON stated Resident 54's mittens were assessed and determine not to be a restraint and the responsible party had given consent. After a review of the record, the DON admitted there was no consent signed by Resident 54's responsible party.
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Page 9 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or potential for actual harm
Based on observation interview and record review, the facility failed to ensure one of 26 sampled residents (54) restraint use was documented on the MDS (assessment tool that directs resident care).
Residents Affected - Few
As result, Resident 54's mittens were not correctly identified.
Findings: On 5/19/22, At 9:44 A.M., Resident 54, was observed awake in bed with mittens on both hands. Resident 54 was constantly moving his hands in an attempt to remove the mittens and trying to scratch. Resident 54's clinical record was reviewed on 5/19/22. A note from the dermatologist, dated 4/27/22, indicated to keep mittens on bilateral hands to prevent patient from scratching. There was a single care plan developed for the use of the mittens the care plan only directed staff to monitor every shift for breakdown and placement. There was nothing on the most recent MDS to indicate Resident 54 had mittens. On 5/19/22 at 3:04 P.M., the MDS Coordinator was interviewed. The MDS coordinator stated the mittens were not a restraint, they were to stop him from scratching. The MDS coordinator felt the mittens were for safety, not a restraint. The mittens were not coded on the MDS as a restraint or for safety.
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Page 10 of 23
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05/20/2022
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 - Few
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 observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan was provided for one of 26 sampled residents (Resident 104). As a result, Resident 104's hearing loss was not addressed.
Findings: Per the admission record, Resident 104 was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Resident 104 had a BIMS (Brief Interview of mental status, mental status assessment; score 8-12, moderately impaired cognition, 13-15 intact cognition) of 10. On 5/17/22 at 8:45 A.M., Resident 104 was observed in her room laying in bed. Resident 104 was interviewed at this time. Resident 104 stated, I can't hear you. Come closer. My ears are plugged. I can't hear you. On 5/17/22 at 8:50 A.M, the CNA 21 who was assigned to Resident 104 was interviewed. CNA 21 stated, You have to talk loud. She's hard of hearing. On 5/18/22 at 8 A.M., the Nurses Progress notes were reviewed. Resident 104's Nurses admission notes dated 6/25/2020 indicated, .admission note: .Sensory .We need to speak loudly. On 5/18/22 at 9 A.M., The SSD was interviewed. The SSD stated, The nurses identify when a resident needs to see a specialist. Social services would arrange the appointment and transportation. Furthermore, the SSD stated, (Resident 104) has not seen an audiologist (Ear doctor) since she was admitted . On 5/18/22 at 9:10 A.M., a concurrent interview and record review with the LN 22 was conducted. LN 22 stated, I do not see a care plan for (Resident 104)'s hearing loss. LN 22 stated, An RN usually looks over the admission assessment and creates a careplan. The resident's hearing loss should have had a care plan.
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Page 11 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
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 follow a physician's order for a Restorative Nursing Assistant (RNA) dining program as ordered for one of one sampled resident (102).
Residents Affected - Few This failure had the potential to result in Resident 102 to lose more weight.
Findings: Resident 102 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to the brain), dysphasia (difficulty swallowing), and adult failure to thrive (poor nutrition and weight loss) per the facility's admission Record. Per Resident 1's Physician Order Summary Report, dated 5/19/22, the physician wrote an order for RNA RDP [restorative dining program] for all meals on 4/8/22. On 5/18/22 at 8:30 A.M., Resident 102's breakfast observation was conducted in the room. There was a breakfast tray with slightly eaten pureed pancake on the bedside table in front of Resident 102. No staff was observed during breakfast in the room. On 5/18/22 at 1:03 P.M., a concurrent observation and interview of Resident 102's lunch was conducted with Rehabilitation (Rehab) 30. Rehab 30 was observed sitting next to Resident 102 assisting with meal. Rehab 30 stated Resident 102 was not able to eat by herself and needed assistance. No other staff was observed during lunch in the room. On 5/19/22 at 10:20 A.M., an interview with Certified Nurse assistant (CNA) 32 was conducted. CNA 32 stated Resident 102 refused to eat meal and required assistance with eating. 5/19/22 at 10:38 A.M., a concurrent interview and record review of Resident 102 was conducted with Licensed Nurse (LN) 31. LN 31 stated Resident 102 had an order for an RNA to assist all meals. LN 31 stated her expectation was the RNA to assist the resident to eat for all meals. On 5/19/22 at 11:02 A.M., an interview with RNA 30 was conducted. RNA 30 stated RNAs did not assist Resident 102's meal because she was not on the RNA feeding program. RNA 30 stated he was not informed that Resident 102 had the order for an RNA dining program. On 5/20/22 at 9:40 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the RNA should have assisted Resident 102's meals according to the physician's order. The DON stated her expectation was the staff to follow the physician's order. According to the Scope of Regulations excerpt for the Business and Professions Code Division 2, Chapter 6. Article 2, Section 2725, Legislative Intent: Practice of Nursing Defined of the California Nursing Practice Act, dated 2012, . (b) The Practice of nursing . including all of the following . (2) direct and indirect patient care services . necessary to implement a treatment, disease preventing or rehabilitative regime ordered by and within the scope of licensure of a physician.
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Page 12 of 23
555206
05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0675
Honor each resident's preferences, choices, values and beliefs.
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 safely position one of two sampled resident (Resident 104) during a meal.
Residents Affected - Few This deficient practice put Resident 104 at risk for choking and aspiration.
Findings: Per the admission Record, Resident 104 was admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain tissues which cause parts of the brain to die off) affecting left non-dominant side. On 05/17/22 at 8:45 A.M., during a meal observation, Resident 104 was observed in her room. Resident 104 was awake, on her right side with the head of her bed at a 20 degree angle. Resident 104 was observed using her right hand to attempt to feed herself as she slowly reached for the food on her tray. On 05/17/22 at 8:50 A.M., CNA 21 was interviewed. CNA 21 stated, The head of the bed should be higher and she should be closer to her tray. On 05/17/22 at 9 A.M., the activities assistant (AA) was interviewed. The AA stated, the head of her bed should have been higher to prevent aspiration. On 5/18/22 at 11 A.M., the RD was interviewed. The RD stated, The resident's head of bed should have been at least 45 degrees to avoid aspiration. Review of a policy titled, Activties of Daily Living (ADL) Supporting . 2. Appropriate care and services will be provided to residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with .d. Dining (meals).
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Page 13 of 23
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05/20/2022
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
Based on observation, interview, and record review the facility failed to provide one of 26 sampled resident (33) who was non-English speaking resident with a communication board.
Residents Affected - Few
As a result, the resident had difficulty communicating with staff.
Findings: Resident 33 was admitted to facility with diagnoses including Respiratory Failure ( a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems), and Dysphagia (difficulty swallowing) per facility's admission record. Record review of MDS Section C, Cognitive Patterns was conducted. Resident 33 had a BIMS score(Brief Interview of mental status, mental status assessment; score 8-12, moderately impaired cognition, 13-15 intact cognition) of 10. On 5/18/22 at 12:48 P.M., an interview and observation of Resident 33 was conducted. Resident 33 stated he preferred to speak Spanish, but understood a lot of English. He was able to respond in single word responses in Spanish, but some garbling of speech. Resident 33's room had no visible signs that resident spoke Spanish and no communication board in room. On 5/20/22 at 9 A.M., an interview and observation with LN 1 as translator for Resident 33 was conducted. Per LN 1's translation, Resident 33 stated that he did not get help immediately if there was no Spanish speaking staff working. Resident 33 stated he never had a communication board since he had been at the facility. On 5/20/22 at 9:18 A.M., an interview with LN 4 was conducted. LN 4 stated she had taken care of Resident 33 in the past, and was usually able to communicate with him in her broken Spanish. She stated he would benefit from a translation board with simple phrases, like hungry,thirsty or pain, for those times when Spanish speaking staff were not available. LN 4 stated the expectation was the resident should have a basic way to communicate with staff at all times. On 5/20/22 at 2:34 P.M., an interview with the DON was conducted. The DON stated the resident would have benefited from the communication board in times when Spanish speaking staff was not available to translate. She stated that without a communication board, Resident 33 might not be able to communicate clearly with staff who didn't speak Spanish. A record review of facility policy titled, Translation and/or Interpretation of Facility Services, was conducted. This Policy indicated, This facility's language access program will ensure that individuals with limited English proficiency have meaningful access to information and services provided by the facility.
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Page 14 of 23
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0694
Provide for the safe, appropriate administration of IV fluids 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 midline catheter (a catheter placed into a vein in the upper arm) dressing was changed accordance to the facility's policy for one of 26 sampled resident (55).
Residents Affected - Few
As a result, Resident 55 was placed at risk for infection.
Findings: Resident 55 was admitted on [DATE] with diagnoses that included Type 2 Diabetes (illness with high blood sugar level), per the facility's admission Record. Per facility's progress note, dated 5/4/22, Resident 55 had a midline on the left upper arm upon admission to the facility. On 5/17/22 at 3:55 P.M., an observation and interview were conducted with Resident 55. Resident 55 was observed in bed with a dressing dated 5/3, covering a vascular access device on the left upper arm. Resident 55 stated the dressing had never been changed since she arrived at the facility. On 5/18/22 at 10:08 A.M., a concurrent observation and interview of Resident 55's midline dressing was conducted with LN 30. LN 30 stated the dressing was dated 5/3 and the dressing did not look clean. LN 30 stated the midline dressing needed to be changed every seven days. On 5/18/22 at 10:15 A.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated the midline dressing needed to be changed every seven days. On 5/20/22 at 9:31 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated her expectation was the nurse to change the midline dressing every 7 days per facility's policy. The DON further stated it was important to change the dressing per protocol because the resident could have developed an infection. According to the facility's policy, titled Midline Dressing changes, revised April 2016, .1. Change midline dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way .
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Page 15 of 23
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to post their actual staffing hours when they only posted projected staffing for the day.
Residents Affected - Few
As a result, due to changes in staffing these numbers may have been incorrect.
Findings: On 5/18/22 at 10:30 A. M., the facility Administrator was asked for posted staffing information for the last 2 weeks including today. The DON presented posted staffing information for 5/1/22 to 5/14/22, at that time the DON was asked for actual staffing hours as the information provided was only the projected staffing. The DON provided the Census and Direct Care Service Hours Per Patient Day, for this period. This form contained the actual staffing for each day. On 5/10/22, the Projected Boulder Creek Post Acute Care, documented the total staff hours as 476.5, the Census and Direct Care Service Hours Per Patient Day documented the actual hours as 448.57, a difference of 29 staffing hours. On 5/11/22, the Projected Boulder Creek Post Acute Care, documented the total staff hours as 468, the Census and Direct Care Service Hours Per Patient Day documented the actual hours as 463.9, a difference of 4 staffing hours. On 5/12/22, the Projected Boulder Creek Post Acute Care, documented the total staff hours as 484.5, the Census and Direct Care Service Hours Per Patient Day documented the actual hours as 452.96, a difference of 31 staffing hours. On 5/19/22 at 10 A.M., the DON confirmed they only post the projected staffing hours, they do not adjust the Projected Boulder Creek Post Acute Care form to reflect any changes in staffing for the day.
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05/20/2022
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 use the correct scoop size for vegetables during tray line.
Residents Affected - Few As a result, the residents did not receive the appropriate amount of vegetables served.
Findings: On 5/18/22 at 11:45 A.M., the CK was observed placing scoops with different colored handles next to the food inserts on the steam table. CK was interviewed at this time. CK stated, The gray scoop, #8 will be used for the (starch), the green scoop, #12 will be used for the vegetables, a gray scoop, #8 will be used for pureed meat. Tray line started production at 11:50 A.M., and ended at 12:58 P.M. On 5/18/22 at 1:30 P.M., the CK was interviewed. The CK stated, The gray scoops are equal to 4 ounces, the green scoops are equal to 3 ounces. On 5/18/22 at 3 P.M., a concurrent record review and interview was conducted with the DS. The DS stated, The cook's spreadsheet indicates, the vegetables should have been served with a gray scoop which is equal to 4 ounces. The cook used a green scoop which is 3 ounces. We should have used a 4 ounce scoop. On 5/19/22 at 1:30 P.M., the RD was interviewed. The RD stated, Proper measurement of food is important. 4 ounces is the regular serving and 3 ounces is equal to a small serving of vegetables. The document titled, Cooks spreadsheet , dated 5/18/22, was reviewed. This document indicated, (Vegetable): . Regular- 1/2 cup (#8 scoop/4 ounces). Per the Policy titled, Meal Service, dated 2018, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner
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05/20/2022
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 failed to provide food that was palatable. As a result the residents did not enjoy their food and had the potential to skip meals.
Residents Affected - Few
Findings: On 5/18/22 at 10:30 A.M., during the resident council meeting, 12 of 12 residents complained about the food. On 5/18/22 at 11:45 A.M., trayline was observed. At 12:58 P.M., the last tray on the trayline was taken to station one. A test tray was requested and tasted by the survey team and DS. The menu included Garden Fresh Meatloaf and gravy, mashed potatoes, Spinach AuGratin, garlic bread and chocolate peanut butter bars. The potatoes, spinach, bread and dessert were found to be palatable. The tasters found the meatloaf and gravy to have an unusually sweet taste. On 5/18/22 at 2:30 P.M., Resident 39 stated, The gravy had an off taste. It did not taste like gravy, I didn't like it. On 5/19/22 at 2:30 P.M., the DS was interviewed. The DS stated, The gravy was a little sweet. The DS further stated, I interviewed the cook. He said he added a little brown sugar to the gravy to take away the acidity. On 5/19/22 the meatloaf recipe was reviewed. The meatloaf ingredients were, margarine or oil, onions, carrots, celery, bell peppers, Italian seasoning, ground beef, rolled oats or bread crumbs, milk, pasteurized eggs, salt and pepper. The Gravy recipe was reviewed. The gravy ingredients were, melted margarine or pan drippings, all-purpose flour, onion powder, salt, black pepper, low-sodium soup broth. On 5/19/22 at 2:45 P.M., the RD was interviewed. The RD stated, The main ingredients for gravy are flour, butter and stock. A little sugar to take away acidity is ok but sugar is not in the recipe. The recipe should be followed. Per the policy titled, Food Preparation, dated 2018, .PROCEDURE: .2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.
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05/20/2022
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
Based on observation, interview and record review, the facility did not ensure infection prevention in facility when:
Residents Affected - Some
1. The facility did not clean up feces on residents' floor. 2. The facility did not ensure unvaccinated staff wore proper PPE in a transmission-based precaution room. 3. The facility did not ensure screeners performed Covid screening on vendors and doctors. These failures had the potential for infection to spread in the facility.
Findings: 1. On 5/17/22 at 2 P.M., a concurrent interview with Resident 63 and observation of his room was conducted. He stated that there was often feces on the floor, and under closer inspection it was determined that at time of observation, it was observed there was smeared brown material in the middle of the floor. On 5/17/22 at 2:25 P.M., a concurrent interview and observation with the IP was conducted. The IP observed smeared brown material. She stated that the expectation was that feces should cleaned off the floor as soon as it was seen by staff. She stated that by not cleaning the floors of feces, there could be a spread of infection. On 5/2022 at 2:22 P.M., an interview was conducted with the DON. She stated that the residents' floor should be cleaned of feces immediately, otherwise it could increase spread fecal infections. 2. On 5/18/22 at 3:50 P.M., LN 6 was observed going into a transmission base (disease that can spread) precaution room with only a surgical mask. A sign by resident's doorway was observed with requirements for entering room which included: N95 (more efficient type of mask), eye protection, gown, and gloves to enter. On interview, LN 6 stated, she knew she was not wearing the correct PPE for transmission based precautions per the sign. She stated by not following the policy, she may put herself and others at risk of Covid infection. A record review of facility document titled, Covid-19 Vaccine-Staff 2022, was conducted. It indicated that LN 6 was unvaccinated with exempted status for Covid vaccine. On 5/20/22 at 2:22 P.M., an interview the DON was conducted. The DON stated the expectation was that staff should use correct PPE based on their vaccination status, as well as the Covid status of the residents in their assignment. She stated for an unvaccinated staff providing care on the unit, LN 6 needed to wear N95 and face shield while in facility. She stated that the consequence of not using
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0880
the correct PPE increased possibility of spreading Covid in the facility.
Level of Harm - Minimal harm or potential for actual harm
A record review of facility policy titled, Coronavirus Disease (Covid 19) Mitigation Plan for Skilled Nursing Facility, dated April 2022 was conducted. This policy indicated, .Staff have been trained on selecting, donning, and doffing appropriate PPE and demonstrate competency of such skills during resident care . Signs are posted immediately outside of resident rooms indicating appropriate infection control and prevention precautions and required PPE in accordance with CDPH guidance.
Residents Affected - Some
3. On 5/19/22 at 7:30 A.M., a concurrent interview, observation and record review was conducted with Screener 10 at front desk of facility. Screener 10 stated she checked temperature, proof of vaccination, and symptoms of Covid for all visitors and staff entering. It was observed that an ambulance company came in to pick up a resident, they signed a different log other than staff and other visitors, entitled Contractor Sign In/Out. On review of document with Screener 10, it was noted that there was no Covid Screening on the document. Screener 10 stated that the ambulance staff were frequent visitors, so she didn't screen them again, because she knew them. She stated this may be a problem in that without screening the vendors and doctors, she might allow an infected person into the facility. She stated the expectation should be to do Covid screening for everyone who enters the facility. On 5/19/22 at 1:30 P.M., a concurrent interview and record review of Contractor Sign In/Out was conducted with the IP. She stated, the expectation was the vendor sheet should include symptoms, temperature, and vaccination status. She stated that having no screening on the Contractor Sign In/Out, that infected contractors might be overlooked, and possibly spread infection. On 5/20/22 at 2:22 P.M., a concurrent interview and record review was conducted with the DON. The DON stated that the screening paperwork for vendors and doctors did not have Covid Screening. She stated the consequence of not having Covid screening might allow infected vendors and doctors to spread the infection in the facility. A record review of policy titled, Coronavirus Disease (Covid 19) Plan for Boulder Creek Post Acute, dated September 2021, was conducted. This policy indicated, .The facility screens, including temperature checks, and documents every individual entering the facility (including staff) for Covid 19 symptoms .
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review, the facility failed to prevent residents from using multiple power strips plugged directly into each other.
Residents Affected - Few
As a result, the facility had increased potential risk for electrical fire.
Findings: On 5/17/22 at 9:50 A.M., a concurrent interview and observation was conducted of Resident 90's room. It was observed that Resident 90 had at least 3 power strips plugged into each other from one wall outlet. Resident 90 stated he had a lot of electronics that he liked to keep plugged in to charge. Resident 90 stated that the facility was aware that he used multiple power strips in this manner. On 5/18/22 at 9:45 A.M., a concurrent observation and interview of Resident 44's room was conducted with the MS. Five medical equipments were all plugged into one power strips. The MS stated Resident 44's power strip was non-medical grade power strip and should not had been any medical equipments plugged in. On 5/19/22 at 9:45 A.M., a concurrent interview and observation was done of Resident 90's power strip setup with the MS. The MS stated that connecting multiple power strips into each other was not allowed because it was a fire hazard. He stated that he had discussed this with the resident before, but the MS had not been in Resident 90's room to inspect power strips. The MS stated the expectation was to not plug power strips into one another, as it can be a fire hazard, and is against facility policy. The MS stated the expectation in the future would be to inspect rooms on his regular rounds in the future for this type of power strip setup. A record review of facility policy titled, Electrical safety for Residents dated January 2011, was conducted. This policy indicated, . 2. Inspect electrical outlets, extension cords, power strips, and electrical devices as part of routine fire safety and maintenance inspections .6. Power strips shall not be used as substitute for adequate electrical outlets in facility. A record review of facility policy titled, Power Strip Waiver dated 2022, was conducted. This policy indicated, Maintenance: The electrical equipment that uses power strips must be inspected within regular maintenance program for electrical/mechanical integrity (e.g the casing, power cords, safety covers, and circuit breakers, etc.)
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the call bell system alerted staff to a resident requesting an assistant when the call bell system only lighted up.
Residents Affected - Many As a result, call light may not have been answered in a timely manner.
Findings: On 5/17/22 at 8:55 A.M., Resident 12 was interviewed. Resident 12 stated, I had to wait 2 hours to be changed after pressing the call light. On 5/17/22 at 9:535 A.M., Resident 46 was interviewed. Resident 46 stated, I waited 1 hour for the call bell to be answered. On 5/17/22 at 9:50 A.M., Resident 90 was interviewed. Resident 90 stated that his roommate waited 3 hours for someone to answer the call light. On 5/17/22 at 9:18 A.M., room [ROOM NUMBER] was toured. The resident in room [ROOM NUMBER] required assistance and the in room call bell was activated. There was no audible alert to the call bell, and the call light outside of room did not light up. The Social Services Director was just outside the room, and she stated the call bell had no audible alarm just the light at the door. The Social Services Director stated the staff help residents after identifying the call bell light is on during rounds. She was unaware the call bell light outside room [ROOM NUMBER] did not light up. On 5/18/22 at 10:30 A.M., a resident council meeting was held. Majority of the residents in the meeting voiced a concern regarding long call bell response time throughout the facility. On 5/20/22 at 8:42 A.M., at Station 1. The call bell light was on in room [ROOM NUMBER]. Two staff were sitting at the nurse's station. The call panel at the station, had a light on, but the phone was placed in front of it to block anyone seeing that light. The light was on but there was no sound at all, to indicate a resident used a call bell to summon help. A few minutes later, on Station 2, again a light was on outside of a resident's room, the call bell panel was lit up. There was barely a beeping sound at the control panel. If you were more than a few feet away from the desk, you would not have heard the sound. The facility provided their Answering the Call Light policy, last revised in October 2010. The policies general guidelines 7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the residents call as soon as possible. 9. Be courteous in answering the resident's call. Steps in the procedure. 1. Turn off the signal light. 2. Identify yourself and call the resident by his/her name . The policy did not address how the call bell summons help. Whether it is audible or visual, or how staff are to monitor the residents rooms to ensure they identify a call light has been activated promptly.
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05/20/2022
Boulder Creek Post Acute
12696 Monte Vista Road Poway, CA 92064
F 0921
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the handrails in the hallway was safe for the residents, staff, and visitors. This failure had the potential for all residents using the handrails to be at risk for injuries.
Findings: On 5/18/22 at 12:26 P.M., a handrail on the hallway in station 1 across from room [ROOM NUMBER] was observed to have a square shaped plastic patched on the original handrail. The edges of the plastic patch had rough and sharp edges upon touch. On 5/19/22 at 11:20 A.M., a concurrent observation and interview with MS was conducted. The MS stated the handrail across from room [ROOM NUMBER] was patched up with rough edges and it was not safe for the residents. The MS stated this needed to be taped until the new parts came in. He further stated the maintenance did environmental rounds on each station but was not aware of this handrail's condition. On 5/20/22 at 9:48 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the handrails in the hallway should not have any rough edges and was not safe for the residents. The DON stated it was a safety issue because anyone touching the handrail could have gotten hurt. According to the facility's policy titled, Maintenance Service, revised December 2009, .b. Maintaining the building in good repair and free from hazards .
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Back to topCitations
20 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
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.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F675 - Quality of life
Honor each resident's preferences, choices, values and beliefs.
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.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
FAQ · About this visit
Common questions about this visit
What happened during the May 20, 2022 survey of BOULDER CREEK POST ACUTE?
This was a inspection survey of BOULDER CREEK POST ACUTE on May 20, 2022. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BOULDER CREEK POST ACUTE on May 20, 2022?
Yes, 20 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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.