Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boulder Creek Post Acute during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment for residents, as screws were found protruding from handrails, posing a risk of injury. Staff, including a CNA, MD, and DON, confirmed the hazard, acknowledging that the sharp screws could harm residents. The facility's maintenance policy requires the building to be free from hazards, which was not followed.
The facility failed to maintain food safety and sanitation practices, with deficiencies including dented and rusted cans in storage, an expired frosting mix, a non-functional garbage disposal, and a dishwashing machine not reaching sanitary temperatures. The Dietary Supervisor and Dietary Aide acknowledged these issues, which were contrary to the facility's policies and posed a potential risk to the health of 143 residents.
The facility failed to manage outdoor garbage and refuse properly, resulting in overfilled dumpsters with open lids near the kitchen exit. This was observed during an interview with the Dietary Supervisor, who acknowledged the issue. Pest control reports indicated heavy rodent activity near the dumpsters, and the Director of Nursing expected dumpsters to be securely closed. The facility's sanitation and pest control policies were not followed, and a specific disposal policy was not provided.
The facility failed to maintain an effective pest control environment, resulting in an ant infestation in the kitchen floor drain near the dishwashing machine. The Dietary Supervisor noted that food accumulation attracted the ants, and the Director of Nursing confirmed that daily cleaning was expected but not documented in the cleaning schedule. This posed a risk of food contamination and food-borne illnesses to the 143 residents receiving food from the kitchen.
A facility failed to notify the State LTC Ombudsman of a resident's transfer to a hospital due to norovirus, resulting in a lack of advocacy support for appeal rights. Staff interviews revealed confusion over notification responsibilities, leading to the oversight despite policy requirements.
A resident was transferred to a hospital without being notified of the facility's bed hold policy, which allows for a reserved bed upon return. The facility failed to provide written notice to the resident or family within the required timeframe, and the bed hold consent form was incomplete. Staff interviews confirmed the lapse in communication and documentation.
The facility failed to conduct Level II Mental Health Evaluations for two residents diagnosed with mental illnesses, potentially leaving their mental health needs unmet. The MDS nurse confirmed that evaluations should have been conducted, but the facility's PASRR Completion Policy lacked guidance for reevaluating residents with new mental illness diagnoses.
A resident with type 2 diabetes had multiple high blood sugar readings, but the facility failed to notify the physician as required. The MAR showed several readings over 290, yet there were no progress notes indicating physician notification. Interviews with the DSD and DON confirmed that nurses did not document or communicate these readings, violating the facility's policy.
A resident with a PICC line for IV antibiotics did not receive timely dressing changes as per facility policy, which requires changes every 5-7 days. Despite the resident's report and staff confirmation that no changes were made since admission, there was no documentation to support compliance with the dressing change schedule, exposing the resident to potential infection risks.
A resident with COPD and severe cognitive deficits was not properly monitored before and after nebulizer treatments, as required by facility policy. Observations showed improper maintenance of nebulizer equipment, and interviews revealed inconsistent documentation of vital signs. The DON acknowledged the need for pre and post-treatment monitoring, which was not followed, potentially affecting treatment effectiveness and resident safety.
A facility did not respond to a pharmacist's recommendation to conduct a lipid panel for a resident with hyperlipidemia. Despite the recommendation being documented, there was no evidence of the lipid panel being completed in the resident's medical record. The DON acknowledged the oversight, which was contrary to the facility's policy on responding to pharmacist recommendations.
A facility failed to accurately document a resident's medication on weekly summaries. A resident with schizoaffective disorder had an order for risperidone, but the weekly summaries by an LN incorrectly stated no antipsychotic medication was used. The LN admitted to overlooking the order, and the DON acknowledged the need for accurate completion of summaries. Facility policy requires complete and accurate documentation.
A resident with COPD experienced potential infection risks due to improper maintenance and storage of nebulizer equipment. Observations showed condensation on the equipment, indicating it was not cleaned or dried properly. Inconsistent cleaning practices were noted among respiratory therapists, with one using sink water and sanitizer wipes, while another stressed the use of sterile water. The DON confirmed the importance of following proper cleaning procedures as per facility policy.
The facility failed to secure handrails in the hallways, posing a risk of injury to residents. Observations revealed a loose handrail, confirmed by a CNA and LN, who noted that residents rely on these for support. The facility's maintenance policy requires the building to be free from hazards.
A facility failed to follow self-administration protocols when an LPN left medications not approved for self-administration on a resident's bedside table. The resident was approved to self-administer specific medications, but the LPN left aspirin, furosemide, and vitamins unattended, which were not approved for self-administration. The LPN admitted to leaving the medications as a favor, knowing it was against protocol.
A resident with moderately impaired cognition was found to have a used urinal placed on their meal tray table, which they also used for meals. The facility failed to develop a baseline care plan or provide education on infection prevention, as confirmed by the Infection Preventionist and Assistant Director of Nursing. This oversight was contrary to the facility's policy on comprehensive, person-centered care plans.
A resident in a LTC facility, cognitively intact and readmitted with post-surgery and diabetes care, found a used urinal on their meal tray table, which was placed by staff from a previous shift. This action violated the facility's infection control policy. Staff interviews confirmed the breach, acknowledging the importance of preventing infection spread.
Protruding Screws in Handrails Pose Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for all 28 sampled residents, as screws were observed protruding from handrails inside the facility. On two consecutive days, eight handrails were found with screws sticking out at a height where individuals using the handrails would come into contact with the sharp ends. During interviews, a Certified Nursing Assistant (CNA), the Maintenance Director (MD), and the Director of Nursing (DON) all acknowledged the potential for injury, noting that the screws were sharp and could cause harm if a resident grabbed the handrail. The facility's policy on maintenance service requires maintaining the building in good repair and free from hazards, which was not adhered to in this instance.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as evidenced by several deficiencies observed during a kitchen tour. A dented can of diced peaches and two rusted cans of pie filling were found in the dry storage pantry, which the Dietary Supervisor acknowledged should have been discarded to prevent potential food-borne illnesses such as botulism. Additionally, a frosting mix with an expired use-by date was found in the pantry, which the Dietary Supervisor and Dietary Aide confirmed should not have been used due to the risk of making residents sick. The facility also failed to maintain kitchen equipment in good working condition. A garbage disposal attached to a sink was found to be non-functional and had not been maintained for over a year, with visible calcium deposits and rust. The Dietary Supervisor and Dietary Aide noted that the garbage disposal should be cleaned daily to prevent contamination of food prepared in the kitchen. Furthermore, the low-temperature dishwashing machine was observed to not reach the required sanitary temperature levels, with the temperature gauge indicating 109°F and 118°F, below the necessary 120°F to ensure proper sanitation of dishware and utensils. Interviews with the Director of Nursing revealed an expectation for the kitchen to be sanitary with clean and working equipment, and for food items that are expired, dented, or rusted to be discarded. The facility's policies and procedures support these expectations, indicating that equipment should be maintained in good repair and that food storage guidelines should be followed to prevent food-borne illnesses. However, the observed deficiencies in food storage, equipment maintenance, and sanitation practices indicate a failure to adhere to these standards, posing a potential risk to the health and safety of the 143 residents receiving food from the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly manage outdoor garbage and refuse, leading to an observed deficiency. During an observation and interview with the Dietary Supervisor, it was noted that two dumpsters located outside the loading dock area near the kitchen hall exit were overfilled with trash, including clear plastic trash bags and brown cardboard boxes, with their lids fully open. Additionally, two wet plastic bags were found on the ground near one of the dumpsters. The Dietary Supervisor acknowledged that the dumpsters should not have been overfilled and that the lids should have been closed to prevent pests from accessing the trash, which could lead to the spread of germs and contamination within the facility. The facility's pest control service reports from December 2024 and January 2025 indicated heavy rodent activity near the dumpsters at night, with recommendations to cover, close, repair, or replace the trash cans. The Director of Nursing expressed that the expectation was for dumpsters and trash bins to be securely closed to prevent pest infestation. The facility's sanitation policy required kitchen waste to be kept in leak-proof, non-absorbent, and tightly closed containers, and the pest control policy stated that garbage and trash should not accumulate and must be removed from the facility. However, the facility did not provide a specific policy and procedure for the disposal of garbage and refuse.
Ant Infestation in Kitchen Floor Drain
Penalty
Summary
The facility failed to maintain an effective pest control environment, as evidenced by an infestation of ants in the kitchen floor drain near the low-temperature dishwashing machine. During an initial kitchen tour, it was observed that the floor drain was surrounded by a brownish/black, mud-like substance with mixed food particles, which attracted ants. The Dietary Supervisor (DS) acknowledged the presence of ants and attributed it to food accumulation from the drainage pipes. The DS also stated that the floor drains and drainage outlets should be cleaned daily to prevent such infestations. Further investigation revealed that the facility's cleaning schedule from December 2024 through February 2025 did not include records of routine cleaning for floor drains. The Director of Nursing (DON) confirmed that the expectation was for daily cleaning of floor drains to prevent pest attraction and potential contamination of food. Despite having a policy for an ongoing pest control program, the facility failed to implement effective measures to keep the kitchen free of insects, posing a risk of food contamination and food-borne illnesses to the 143 residents receiving food from the kitchen.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman regarding the transfer of Resident 139 to an acute care hospital. Resident 139, who had a history of atrial fibrillation, was transferred to the hospital due to a positive norovirus diagnosis. Despite the requirement to send a copy of the transfer/discharge notice to the ombudsman's office, the facility did not do so, resulting in a lack of notification to the ombudsman and potential advocacy support for the resident's appeal rights. Interviews with various staff members, including the Medical Records Director, Social Services Director, licensed nurse, Admissions Coordinator, and Director of Nursing, revealed confusion and lack of clarity regarding the responsibility for notifying the ombudsman. Each staff member believed that another department or individual was responsible for the notification, leading to the oversight. The facility's policy indicated that a copy of the notice should be sent to the ombudsman at the same time it is provided to the resident and representative, but this procedure was not followed in the case of Resident 139.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident, identified as Resident 139, or his family member in writing about the option to request a bed hold when the resident was transferred to an acute care hospital. Resident 139 was admitted to the facility with a history of atrial fibrillation and was transferred to the hospital due to a positive norovirus diagnosis. Upon review, it was found that there was no documentation in Resident 139's clinical record indicating that the facility's bed hold policy was communicated to the resident or his family at the time of transfer. Interviews with facility staff, including a licensed nurse and the Admissions Coordinator, revealed that the bed hold policy was not provided to Resident 139 or his family within the required 24-hour period. The Director of Nursing confirmed that the nurses were responsible for informing residents about the facility's seven-day bed hold policy upon admission. However, the necessary sections of the bed hold consent form for Resident 139 were not completed, indicating a lapse in the facility's procedure to ensure residents and their families are informed about bed hold options and potential out-of-pocket expenses.
Failure to Conduct Level II Mental Health Evaluations
Penalty
Summary
The facility failed to reevaluate two residents for mental health services, leading to potential unmet mental health needs. Resident 2 was admitted with diagnoses of major depressive disorder and schizoaffective disorder, but there was no documentation of a Level II Mental Health Evaluation being conducted. The MDS nurse confirmed that Resident 2 should have been reviewed for this evaluation upon diagnosis. Similarly, Resident 57 was admitted with PTSD and bipolar disorder and later diagnosed with major depressive disorder. However, there was also no documentation of a Level II Mental Health Evaluation for this resident. The MDS nurse acknowledged that Resident 57 should have been reviewed for the evaluation following the new diagnosis. The facility's PASRR Completion Policy did not instruct staff to reevaluate residents with new mental illness diagnoses.
Failure to Notify Physician of High Blood Sugar Readings
Penalty
Summary
The facility failed to notify the physician of high blood sugar readings for a resident diagnosed with type 2 diabetes mellitus, which resulted in an increased risk of untreated symptoms of high blood sugar. The resident had multiple blood sugar readings exceeding 290, as recorded in the Medication Administration Record (MAR) for January 2025. These readings included 322, 293, 337, 313, 294, and 305 on various dates. However, there were no progress notes indicating that the physician was notified of these high readings, as required by the facility's policy. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the nurses responsible for taking the high blood sugar readings did not notify the physician or document the notification in the progress notes. The facility's policy, titled 'Guidelines for Notifying Physicians of Clinical Problems,' mandates that the floor nurse should contact the attending physician if a clinical situation requires immediate discussion and management. The lack of documentation and communication with the physician led to the deficiency identified in the report.
Failure to Change PICC Line Dressing as Per Policy
Penalty
Summary
The facility failed to adhere to professional standards of care for the management of a peripherally inserted central catheter (PICC) dressing for a resident receiving intravenous medications. The resident, who was admitted with a history of osteomyelitis and had undergone a middle toe amputation, had a PICC line in the right upper arm that was not changed since admission. The resident reported that no dressing changes had been performed by the nursing staff, despite being on IV antibiotics. Interviews with licensed nurses and the Director of Nursing confirmed that the PICC line dressings should be changed weekly to prevent infection and complications. However, there was no documentation to support that the dressing was changed within the required timeframe. The facility's policy indicated that dressings should be changed every 5-7 days, aligning with CDC guidelines. The failure to change the dressing as per policy exposed the resident to potential infections and complications.
Failure to Monitor Respiratory Care for Resident on Nebulizer
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident using a nebulizer, leading to a deficiency in care. Resident 38, who has a history of chronic obstructive pulmonary disease (COPD) and severe cognitive deficits, was not properly monitored before and after nebulizer treatments. Observations revealed that the nebulizer equipment was not maintained properly, with condensation present on the mask and chamber. Interviews with licensed nurses and respiratory therapists indicated that there was no consistent documentation of pre and post-treatment respiratory vital signs, which are crucial for assessing the effectiveness of the treatment and monitoring for complications. The Director of Nursing acknowledged that the facility's policy required monitoring of respiratory vital signs before and after nebulizer treatments, but this was not adhered to. The respiratory therapists admitted to only taking vital signs once during the treatment, which is against the facility's policy. This lack of proper monitoring and documentation could lead to ineffective treatment and potential respiratory complications for the resident.
Failure to Respond to Pharmacist's Recommendation for Lipid Panel
Penalty
Summary
The facility failed to respond to a pharmacist's recommendation regarding a resident with hyperlipidemia, a condition characterized by high levels of fat in the blood. The resident was admitted with this diagnosis, and the facility's Consultant Pharmacist recommended a lipid panel to assess the resident's condition. However, there was no documentation indicating that the facility acted on this recommendation. A review of the resident's electronic medical record confirmed that a lipid panel was not completed. During an interview, the Director of Nursing acknowledged that the facility should have responded to the pharmacist's recommendation, as per the facility's policy on documenting responses to pharmacist recommendations.
Inaccurate Medication Documentation for Resident
Penalty
Summary
The facility failed to accurately document a resident's medication on the weekly summary for one of the sampled residents. Resident 2, who was admitted with a diagnosis of schizoaffective disorder, had an order for risperidone, an antipsychotic medication, dated 6/20/24. However, the weekly summaries completed by Licensed Nurse (LN) 21 on 1/12/25, 1/19/25, 1/26/25, and 2/9/25 incorrectly documented that Resident 2 had not been using antipsychotic medication over the last seven days. During an interview, LN 21 admitted to overlooking the risperidone order when completing the summaries. The Director of Nursing (DON) acknowledged that the weekly summaries should have been accurately completed and that the LN should have checked the resident's orders when completing the summaries. The facility's policy on Charting and Documentation requires that documentation in the medical record be complete and accurate.
Inadequate Infection Control for Nebulizer Equipment
Penalty
Summary
The facility failed to adhere to infection control practices for a resident with chronic obstructive pulmonary disease (COPD), leading to potential respiratory complications. The resident's nebulizer equipment was improperly maintained and stored, with observations noting condensation on the mask and chamber, indicating it was not cleaned or dried properly. The respiratory therapist confirmed that the equipment appeared used and not cleaned, which posed an infection control issue as it was not stored in a manner to prevent contamination. Interviews with respiratory therapists revealed inconsistencies in cleaning procedures, with one therapist using sink water and sanitizer wipes, while another emphasized the importance of using sterile water to prevent contamination. The Director of Nursing acknowledged the necessity of following proper cleaning procedures using sterile water, as outlined in the facility's policy, to prevent respiratory illnesses and infections. The facility's policy specified that semi-critical items, such as respiratory therapy equipment, should be free from all microorganisms, highlighting the deficiency in the facility's infection control practices.
Unsecured Handrails Pose Risk to Residents
Penalty
Summary
The facility failed to ensure that handrails in the hallways were appropriately secured, which had the potential to cause injury to all residents. During observations on two consecutive days, a loose handrail was noted, with its ends moving in both directions from level. A certified nursing assistant (CNA) confirmed that the handrails should not move in such a manner and expressed concern that a resident could be injured if the handrail tilted while being used for support. A licensed nurse (LN) also acknowledged that residents relied on the handrails for support and that unsecured handrails could lead to major injuries. The facility's policy on maintenance service indicated that maintenance personnel were responsible for maintaining the building in good repair and free from hazards.
Failure to Implement Self-Administration Protocol
Penalty
Summary
The facility failed to implement a self-administration recommendation for a resident when a licensed nurse left medications that were not approved for self-administration on the resident's bedside table. Resident 3 was admitted to the facility with orders allowing self-administration of specific medications, including topical diclofenac pain gel and cyclosporine eye drops. However, on December 31, 2024, a licensed nurse left aspirin, furosemide, and two vitamins unattended on the resident's bedside table, which were not approved for self-administration. The nurse admitted to leaving the medications as a favor to the resident, despite knowing it was against protocol. This resulted in the medications being left unwitnessed and not administered as ordered.
Failure to Develop Baseline Care Plan for Infection Control
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as Resident 4, which led to a potential risk of infection. Resident 4, who was admitted with a diagnosis including diabetes, had a moderately impaired cognition as indicated by a BIMS score of 10/15. During an unannounced onsite visit, it was observed that a used urinal was placed on top of the meal tray table in Resident 4's room, which the resident confirmed was used for meals. The staff, including a CNA, indicated that the resident placed the urinal on the table, but there was no care plan developed to address this preference or to educate the resident on infection prevention. The Infection Preventionist and the Assistant Director of Nursing both acknowledged that urinals should not be placed on meal tray tables due to infection control practices. They stated that a care plan should have been developed to include education for the resident about infection prevention. The facility's policy on comprehensive, person-centered care plans requires that such plans include measurable objectives and timetables to meet the resident's needs, which was not implemented in this case. This lack of a care plan and education had the potential to lead to an infection for Resident 4.
Infection Control Breach with Used Urinal Placement
Penalty
Summary
The facility failed to implement its infection control program when a used urinal was placed on top of a resident's meal tray table. This incident involved a resident who was readmitted to the facility with diagnoses including aftercare following surgery and diabetes. The resident was cognitively intact, as indicated by a BIMS score of 15/15. During an observation, the resident was found sitting in a wheelchair with a used urinal on the meal tray table, where a jar of olives was also present. The resident confirmed that the urinal was placed there by staff from the previous shift and expressed concerns about the unsanitary condition, stating that the table was used for meals. Interviews with facility staff, including a rehabilitative nursing assistant, the infection preventionist, and the assistant director of nursing, confirmed that the placement of the urinal on the meal tray table was inappropriate and not in line with infection control practices. The facility's policy on infection prevention and control, revised in December 2023, emphasizes maintaining a safe, sanitary, and comfortable environment to prevent the transmission of diseases and infections. The staff acknowledged the importance of preventing the spread of infection and recognized that the urinal should not have been placed on the meal tray table.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Poway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Poway Healthcare Center | 0.6 mi | ★★★★★ | 1 | 0 |
| The Villas At Poway | 0.6 mi | ★★★★★ | 0 | 0 |
| Carmel Mountain Rehabilitation & Healthcare Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Villa Rancho Bernardo Care Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Casa De Las Campanas | 4 mi | ★★★★★ | 0 | 0 |
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