Inspection Reports for
Boulder Post Acute
2121 MESA DR, BOULDER, CO, 80304-3621
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident physical abuse and failure to ensure adequate supervision to prevent accidents and elopement.
Complaint Details
The complaint investigation focused on an incident on 4/16/25 where Resident #2 and Resident #3 physically abused each other resulting in injuries, and an incident on 4/11/25 where Resident #1 eloped from the facility and was missing for approximately 12 hours before being found by police.
Findings
The facility failed to prevent physical abuse between two residents resulting in injury, and failed to ensure adequate supervision and timely response to prevent a resident's elopement, which lasted approximately 12 hours. The facility implemented corrective actions including staff education, increased monitoring, and installation of surveillance cameras.
Deficiencies (2)
Failure to protect residents from physical abuse by other residents resulting in injury including a fracture and bruising.
Failure to ensure an environment free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident eloping from the facility and being missing for approximately 12 hours.
Report Facts
Residents sampled: 10
Residents affected: 2
Residents affected: 1
Weight difference: 117.6
Bruise size: 5
Bruise size: 4
Abrasion size: 3
Abrasion size: 1.5
Pain level: 8
Duration missing: 12
15-minute safety checks missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Requested Resident #2 be put back on Zyprexa and was involved in investigation and interviews related to abuse incident |
| NHA | Nursing Home Administrator | Provided facility policies, conducted investigation, interviewed staff, and implemented corrective actions including staff education and installation of surveillance cameras |
| Psychiatrist | Provided psychiatric care and insight on Resident #2 and Resident #3, interviewed regarding abuse incident | |
| DON | Director of Nursing | Interviewed regarding Resident #2's behavior and medication management, and staff education |
| SSD | Social Services Director | Interviewed regarding resident behaviors and altercations |
| MD | Medical Director | Interviewed regarding psychopharmacological decisions and investigation of abuse incident |
| CNA #2 | Certified Nurse Aide | Failed to investigate front door alarm and did not check on Resident #1 during 15-minute safety checks on 4/11/25 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect a resident from sexual abuse and failure to provide appropriate dementia care interventions.
Complaint Details
The complaint investigation documented an incident of sexual abuse on 1/4/25 where Resident #2 touched Resident #1 in a sexual manner. The sexual abuse was substantiated. Resident #2 had a history of sexually inappropriate behaviors and was placed on one-to-one monitoring after the incident. Resident #1 was found wandering and sleeping in other residents' rooms without effective dementia care interventions in place.
Findings
The facility failed to ensure Resident #1 was kept free from sexual abuse by Resident #2 and failed to develop and implement effective dementia management interventions to prevent Resident #1 from wandering into other residents' rooms. The sexual abuse was substantiated and the facility did not provide person-centered dementia care interventions for Resident #1.
Deficiencies (2)
Failure to protect Resident #1 from sexual abuse by Resident #2.
Failure to provide appropriate treatment and services to a resident diagnosed with dementia, specifically failure to prevent Resident #1 from wandering into other residents' rooms.
Report Facts
Residents affected: 1
Resident age: 75
Frequency of checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Provided facility policies and interviewed regarding the incident and interventions. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about Resident #1 and the incident. | |
| Certified Nurse Aide (CNA) #2 | Interviewed about Resident #1's wandering and behavior. | |
| Licensed Practical Nurse (LPN) #2 | Unit manager interviewed about Resident #1 and Resident #2 monitoring and interventions. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse involving residents, specifically physical abuse between Resident #2 and Resident #3 on 3/21/24, and failure to report and investigate potential sexual abuse incidents involving Resident #2 and Resident #8.
Complaint Details
The complaint investigation was triggered by allegations of physical abuse between Resident #2 and Resident #3 on 3/21/24 and failure to report and investigate two incidents of potential sexual abuse involving Resident #2 and Resident #8. The physical abuse was initially unsubstantiated due to lack of witnesses but later substantiated based on injury consistency. The facility failed to report the sexual abuse incidents timely and failed to investigate them until the survey process.
Findings
The facility failed to ensure residents were free from abuse, failed to timely report alleged abuse incidents to the State Agency, and failed to investigate incidents of potential sexual abuse. The physical abuse between Resident #2 and Resident #3 was initially unsubstantiated but later determined to be substantiated based on injuries consistent with their accounts. The facility also failed to investigate and report two incidents involving Resident #2 and Resident #8.
Deficiencies (4)
Failed to protect residents from physical abuse between Resident #2 and Resident #3 on 3/21/24.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for two incidents involving Resident #2 and Resident #8.
Failed to investigate incidents of abuse involving Resident #2 and Resident #8.
Failed to respond appropriately to all alleged violations involving abuse incidents with Resident #2 and Resident #8.
Report Facts
Residents reviewed for abuse: 9
Residents affected: 5
Residents involved in physical abuse incident: 2
Residents involved in sexual abuse incidents: 2
BIMS score Resident #2: 3
BIMS score Resident #3: 4
Hematoma size Resident #3: 1
Frequency of behavioral monitoring: 1
Progress notes review frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed as abuse coordinator, responsible for directing investigations and reporting abuse incidents | |
| Regional Clinical Consultant (RCC) | Interviewed regarding facility's performance improvement plan and understanding of abuse investigation and reporting |
Inspection Report
Deficiencies: 2
Date: May 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care related to treatment and prevention of wounds, specifically focusing on skin assessments and injury prevention for residents.
Findings
The facility failed to ensure one resident (#3) received appropriate treatment and care for knee wounds, including failure to investigate, treat, and implement interventions to prevent wounds and to complete routine weekly skin assessments as ordered. Documentation and notification regarding the injuries were also lacking.
Deficiencies (2)
Failure to investigate, treat, and implement interventions to prevent wounds to the resident's knees.
Failure to complete routine weekly skin assessments as ordered.
Report Facts
Residents affected: 3
Residents affected: 1
Skin assessments missed: 4
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Observed resident and reported concerns about knee injuries | |
| Unit Manager #1 | Interviewed about awareness of resident's knee injuries | |
| Director of Nursing (DON) | Interviewed regarding resident care, documentation, and facility follow-up plan |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to assess the facility's provision of meaningful activities designed to support residents' physical, mental, and psychosocial well-being, following concerns about lack of activities and personal choice for residents.
Findings
The facility failed to provide meaningful activities, including activities of personal choice, for four of six sampled residents. Deficiencies included lack of notification about activities, limited activity staff availability, insufficient outings, and failure to accommodate residents' preferences and needs.
Deficiencies (1)
Failure to provide meaningful activities to meet all residents' needs, including lack of notification and encouragement for participation.
Report Facts
Residents affected: 4
Sample residents: 42
BIMS scores: 3
BIMS scores: 15
BIMS scores: 15
BIMS scores: 11
Activity staff: 2
Scheduled Bingo activities: 2
Activity participation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #5 | Interviewed regarding failure to inform Resident #70 of Bingo activity | |
| Licensed Practical Nurse #3 | Interviewed about activity staff handing out daily chronicle and snacks | |
| Certified Nurse Aide #6 | Interviewed about activity staff presence and activity cancellations | |
| Activity Director (AD) | Interviewed about activity scheduling, staffing, and outings | |
| Activity Assistant #1 | Mentioned as helping cover weekend activities | |
| Licensed Practical Nurse #1 | Interviewed about Resident #92 and Resident #97 activity participation and needs |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, and food safety at Boulder Post Acute nursing home.
Findings
The facility failed to incorporate PASRR level II recommendations for a resident with serious mental illness, failed to provide meaningful activities tailored to residents' preferences for several residents, and failed to ensure proper labeling, dating, and separation of staff and resident food items in nourishment refrigerators.
Deficiencies (3)
Failed to incorporate recommendations from the PASRR level II notice of determination for Resident #63 with serious mental illness.
Failed to provide meaningful activities designed to support residents' physical, mental, and psychosocial well-being for four residents (#100, #92, #97, and #70).
Failed to ensure food was labeled and dated in nourishment rooms and personal food items belonging to staff were stored in nourishment refrigerators.
Report Facts
Residents reviewed for PASRR: 42
Residents affected by PASRR deficiency: 1
Residents affected by activity deficiency: 4
Residents affected by food storage deficiency: 3
Bingo activity frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #5 | LPN | Interviewed regarding Resident #63's medication refusal and behavior |
| Certified Nurse Aide #4 | CNA | Interviewed regarding Resident #63's behavior and mood swings |
| Nurse Practitioner #1 | NP | Interviewed regarding psychiatric care and therapy for Resident #63 |
| Social Service Director | SSD | Interviewed regarding PASRR initiation and referrals for Resident #63 |
| Social Service Assistant | SSA | Interviewed regarding PASRR services and referrals for Resident #63 |
| Director of Nursing | DON | Interviewed regarding PASRR compliance and food storage policies |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding activities and resident engagement |
| Certified Nurse Aide #6 | CNA | Interviewed regarding activities and resident engagement |
| Activity Director | AD | Interviewed regarding activities scheduling and staffing |
| Activity Assistant #1 | AA | Interviewed regarding activities scheduling and staffing |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #92's activity participation |
| Nurse Manager #1 | NM | Interviewed regarding nourishment refrigerator contents and policies |
| Certified Nurse Aide #2 | CNA | Interviewed regarding staff use of nourishment refrigerators |
| Certified Nurse Aide #3 | CNA | Interviewed regarding nourishment refrigerator use and policies |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, environment, grievance resolution, discharge procedures, activities, quality of care, food service, infection control, and COVID-19 vaccination and testing protocols.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, maintain comfortable environment temperatures, resolve grievances promptly, provide complete discharge summaries, assist with activities of daily living, provide appropriate activities, ensure quality care including honoring hospital transfer requests, serve palatable and nutritionally adequate food, maintain sanitary food service areas, properly store and label food brought by visitors, implement infection control practices including hand hygiene at meals, conduct COVID-19 testing with proper sanitization, and maintain accurate COVID-19 staff vaccination records.
Deficiencies (13)
Failed to ensure residents #99 and #11 had advance directives matching physician orders.
Failed to maintain comfortable room temperatures on Units #1, #2, and #4.
Failed to provide prompt resolution to Resident #89's grievances regarding showers, catheter locks, and cranberry pills.
Failed to provide a complete discharge summary for Resident #144 to ensure safe transition of care.
Failed to provide necessary care for activities of daily living for Residents #99, #11, and #77 including regular showers and nail care.
Failed to provide activities meeting Resident #89's interests and needs, including one-on-one activities.
Failed to provide appropriate treatment and care for Resident #48, including honoring hospital transfer requests and responding to changes in condition.
Failed to ensure food was palatable, attractive, and met nutritional needs; pureed food was gritty and bitter; vegetarian and pureed menu items were not served as planned.
Failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and five satellite kitchens, including unlabeled and undated foods, dirty kitchen surfaces, uncovered trash, improperly cooled food, and holes in kitchen walls.
Failed to implement policy for safe and sanitary storage of foods brought by visitors in resident refrigerators, including lack of labeling, temperature monitoring, and cleaning.
Failed to provide and implement infection prevention and control program including offering hand hygiene to residents prior to meals and staff following proper hand hygiene during meal assistance.
Failed to follow proper COVID-19 testing procedures and infection control measures including disinfecting the testing area between staff tests and during testing periods.
Failed to develop and implement a COVID-19 staff vaccination process ensuring all staff, including agency staff, were vaccinated or had approved exemptions; unvaccinated staff worked without exemption or delay.
Report Facts
Residents reviewed: 44
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 5
Residents affected: 5
Residents affected: 4
Residents affected: 2
Residents affected: 5
Staff affected: 6
Positive residents: 5
Positive staff: 10
Shifts worked: 24
Months worked: 6
Months worked: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #4 | LPN | Primary nurse involved in Resident #48 care and hospitalization events |
| Certified nursing aide #5 | CNA | Worked without primary COVID-19 vaccination or exemption for over six months |
| Dietary aide #1 | DA | Worked without primary COVID-19 vaccination or exemption for over one month |
| Certified nursing aide #4 | CNA | Vaccination status discrepancy noted |
| Licensed practical nurse #4 | LPN | Vaccination status discrepancy noted |
| Certified nursing aide #6 | CNA | Vaccination status discrepancy noted |
Inspection Report
Routine
Census: 136
Deficiencies: 6
Date: Aug 19, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations related to resident care, abuse prevention, dementia care, food service, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse and altercations, failure to prevent misappropriation of resident property, inadequate dementia care planning and activity programming, poor food quality and preparation practices, improper food storage and temperature monitoring, unsanitary food service practices, and inadequate infection control cleaning procedures.
Deficiencies (6)
Failure to protect residents from abuse and neglect, including resident-to-resident physical altercations on the dementia care unit.
Failure to prevent misappropriation of resident property, specifically missing wedding rings of Resident #111.
Failure to provide appropriate dementia care including individualized care plans, non-pharmacological interventions, and meaningful activities for residents with dementia.
Failure to prepare food that conserves flavor and nutritional value; poor food quality and temperature control during meal service.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including unsanitary food service practices, unclean nourishment refrigerators, and incomplete temperature logs.
Failure to maintain an infection control program including inadequate cleaning of high-touch surfaces and improper bathroom cleaning procedures.
Report Facts
Resident census: 136
Residents with dementia diagnosis: 50
Residents with psychiatric diagnosis other than dementia and depression: 57
Residents with behavioral healthcare needs: 67
Behavioral episodes Resident #50: 19
Behavioral episodes Resident #55: 24
Behavioral episodes Resident #6: 19
Food temperatures: 115
Food temperatures: 113
Food temperatures: 129
Food temperatures: 142
Food temperatures: 85
Food temperatures: 117.8
Food temperatures: 64
Food temperatures: 70.5
Refrigerator temperature: 40
Refrigerator temperature: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Observed failing to clean high-touch surfaces and improper bathroom cleaning |
| HRS | Human Resources Staff | Observed serving meals with poor sanitary practices |
| FNS | Food and Nutrition Supervisor | Provided meal service training and observed preparing pureed foods |
| SSD | Social Services Director | Interviewed regarding resident altercations and missing property investigation |
| NHA | Nursing Home Administrator | Interviewed regarding missing resident property and infection control |
| RD | Registered Dietitian | Interviewed regarding food service and sanitation practices |
| IP | Infection Preventionist | Interviewed regarding housekeeping and infection control practices |
| AA #1 | Activities Assistant | Interviewed regarding activity programming on dementia unit |
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