Boulder Creek Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for 28 of 28 sampled residents, when screws were observed protruding from handrails inside the facility. This failure had the potential to cause injury to all facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained with food storage, sanitation, and equipment maintenance according to standards of practice when: 1. One dented large can and two rusted large cans were found in the dry storage pantry. 2. A sink garbage disposal was not functioning and/or maintained in good working condition. 3. A frosting mix with a use by (U/B) date of 1/20/25 was found in the dry storage pantry. 4. Low-temperature dishwashing machine temperature did not reach sanitary temperature levels. These failures had the potential to cause widespread food borne illness among the 143 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure outdoor facility garbage and refuse (recyclable and non-recyclable trash) was not overflowing, and was secure with the dumpster's lids closed, for two facility dumpsters located outside the loading dock area near the kitchen hall exit. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control environment when the kitchen floor drain with food particles was observed infested with ants. This failure had the potential for ants to contaminate food and spread food-borne illnesses to all residents receiving food from the kitchen. The facility census was 143.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the transfer/discharge notice to the ombudsman's office when one of three reviewed discharged residents (Resident 139) required immediate transfer to an acute care hospital for urgent needs. This failure resulted in a lack of resident discharge notification to the State Long Term Care (LTC) Ombudsman representative and the potential advocate, to assist the resident with appeal rights.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three reviewed discharged resident's (Resident 139) or his family member received a notice to request a bed hold when the resident was transferred to the acute care hospital. As a result, Resident 139 and/or his family member did not receive a written notice from the facility at the time of transfer, about the option to pay to hold the resident's bed.

Inspectors wroteBased on interview and record review, the facility failed to reevaluate two of 30 sampled residents (2, 57) reviewed for mental health services. As a result, residents may have had unmet mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a high blood sugar reading for one of 30 sampled residents (23). As a result, Resident 23 had an increased risk of untreated symptoms of high blood sugar.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement professional standards of care for a peripherally inserted central catheter (PICC: catheter [flexible plastic tubing] that is inserted into a vein in either arm and extends all the way to a location near the heart, where medication is delivered) dressing for one of seven sampled residents (Resident 340) receiving intravenous (IV: into the vein) medications, according to the facility's policies and procedures. This failure had the potential to expose Resident 340's PICC site to infections and lead to complications that may negatively impact the resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care according to standards of practice for one of eight reviewed residents (Resident 38) on a nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) treatment. As a result, Resident 38 was not properly monitored before and after nebulizer treatments were provided, and had the potential for ineffective nebulizer administration, respiratory complications, and infections that increased the risk of negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to respond to a pharmacist recommendation related to high levels of fat in the blood, for one of 30 sampled residents (23). This failure had the potential to affect Resident 23's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately document a resident's medications on the weekly summary for one of 30 sampled residents (2). This failure had the potential to miscommunicate Resident 2's status, care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote infection control practices according to standards of practice for one or 30 sampled residents (Resident 38) to prevent respiratory illnesses and infection. This failure had the potential for Resident 38 to experience respiratory complications and infections from improper maintenance and storage of their nebulizer treatment equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure handrails were appropriately secured. This failure had the potential to cause injury to all facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a self administration recommendation for one resident (Resident 3) when a licensed nurse (LN 1) left medications which were not approve for self medication administration on Resident 3' s bedside table. As a result, the unattended medications on Resident 3's bedside table were not witnessed as administered as ordered.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a resident's (Resident 4) baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) for one of one resident reviewed, related to the placement of a used urinal on top of the meal tray table. As a result, the lack of resident centered care plan with specific interventions to prevent contamination of the surface and the lack of education to Resident 4 had the potential for Resident 4 to acquire an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection control program when a used urinal was placed on top of the resident's meal tray table for one of four sampled residents (Resident 1). This failure had the potential for contamination of the surface and could cause an infection to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to fully implement their post fall protocol for a resident who self -reported a fall. This had the potential to compromise the safety and well-being of Resident 1.

Inspectors wroteBased 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. As a result, call light may not have been answered in a timely manner.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform the residents and staff on how to file a grievance. As a result, residents were not able to exercise their rights to file a grievance.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure infection prevention in facility when: 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment for two of two sampled residents (63& 90). As a result the residents did not feel comfortable in their room.

Inspectors wroteBased 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. As a result, resident 54 was subject to an unnecessary restraint.

Inspectors wroteBased 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.

Inspectors wroteBased 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). As result, Resident 54's mittens were not correctly identified.

Inspectors wroteBased 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.

Inspectors wroteBased 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). This failure had the potential to result in Resident 102 to lose more weight.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely position one of two sampled resident (Resident 104) during a meal. This deficient practice put Resident 104 at risk for choking and aspiration.

Inspectors wroteBased 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. As a result, the resident had difficulty communicating with staff.

Inspectors wroteBased 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). As a result, Resident 55 was placed at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to post their actual staffing hours when they only posted projected staffing for the day. As a result, due to changes in staffing these numbers may have been incorrect.

Inspectors wroteBased on observation, interview and record review, the facility failed to use the correct scoop size for vegetables during tray line. As a result, the residents did not receive the appropriate amount of vegetables served.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent residents from using multiple power strips plugged directly into each other. As a result, the facility had increased potential risk for electrical fire.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. As a result, the nutrition of the pureed diets was compromised potentially affecting residents' health.

Inspectors wroteBased 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. As a result, 22 residents were served rice which was bland and carrots which were not seasoned per the recipes.

Inspectors wroteBased on observation, interview, and record review the facility did not display respect for residents when: 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal assistance to one of five residents (17) reviewed for ADLs. This failure had the potential to result in Resident 17 to experience a decrease in ADLs and weight loss.

Inspectors wroteBased 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). As a result, Resident 59 had the potential for low vision or decreased vision.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to monitor one of five residents reviewed for nutrition (78). As a result Resident 78 experienced altered nutrition and experienced a significant weight loss.

Inspectors wroteBased 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. This failure caused Resident 62 to have an dry throat.

Inspectors wroteBased 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: 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. This deficient practice had a potential for Resident 65 to experience difficulty chewing and weight loss, due to not having any teeth or dentures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food safety requirements were followed when: 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNA 31 had a current professional license. This failure created the potential for the facility to be unaware of an active disciplinary action against CNA 31.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure infection control practices were followed when: 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.