Inspection Results » Boulder Creek Post Acute

Health Inspection on October 22, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-02-28)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2019-01-14)
   • 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. (Corrected 2019-02-28)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-04-19)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-04-19)
   • 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 ne (Corrected 2019-01-14)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-02-28)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2019-04-19)
   • Keep residents' personal and medical records private and confidential. (Corrected 2019-01-14)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (Corrected 2019-02-28)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-02-28)
   • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected 2019-01-14)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2019-04-19)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-02-28)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2019-04-19)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2019-02-28)
   • Provide and implement an infection prevention and control program. (Corrected 2019-02-28)
   • 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. (Corrected 2019-02-28)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-02-28)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-01-14)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2019-02-28)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-01-14)
   • Provide appropriate foot care. (Corrected 2019-02-28)
   • Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Corrected 2019-02-28)
   • Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (Corrected 2019-04-19)
   • Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install (Corrected 2019-01-14)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-04-19)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2019-04-19)
   • Ensure meals and snacks are served at times in accordance with residentÂ’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedu (Corrected 2019-02-28)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-02-28)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-04-19)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-04-19)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2019-01-14)