Inspection Reports for
Boulder Post Acute
2121 MESA DR, BOULDER, CO, 80304-3621
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
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: May 13, 2025
Visit Reason
The inspection was conducted following complaints and incidents involving resident-to-resident physical abuse and a resident elopement incident.
Complaint Details
The complaint investigation was triggered by a physical abuse incident between Resident #2 and Resident #3 on 4/16/25, resulting in injuries including a fracture and bruising. Additionally, the facility was investigated for a resident elopement incident on 4/11/25 where Resident #1 left the facility undetected for approximately 12 hours.
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 elopement. The facility implemented corrective actions including staff education, increased monitoring, and installation of surveillance cameras.
Deficiencies (2)
F 0600: The facility failed to protect residents from physical abuse, resulting in injury to two residents during a physical altercation on 4/16/25.
F 0689: The facility failed to ensure adequate supervision and timely response to a door alarm, resulting in a resident eloping for approximately 12 hours on 4/11/25.
Report Facts
Residents in sample: 10
Residents affected: 2
Residents affected: 1
Bruise size: 5
Bruise size: 4
Abrasion size: 3
Abrasion size: 1.5
Pain level: 8
Weight difference: 117.6
Time resident eloped: 12
Elopement risk score: 10
Elopement risk score: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Involved in medication management and investigation of physical abuse incident |
| NHA | Nursing Home Administrator | Provided facility policies, conducted investigation, and implemented corrective actions |
| Psychiatrist | Psychiatrist | Provided clinical insight on Resident #2 and Resident #3's mental health and medication |
| DON | Director of Nursing | Interviewed regarding resident behaviors and medication management |
| SSD | Social Services Director | Interviewed regarding resident behaviors and incident history |
| MD | Medical Director | Interviewed regarding psychopharmacological decisions and resident care |
| CNA #2 | Certified Nurse Aide | Witnessed door alarm incident and failed to investigate; interviewed about elopement incident |
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: 2
Date: Feb 4, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse and inadequate dementia care at the facility.
Complaint Details
The complaint investigation substantiated that Resident #1 was sexually abused by Resident #2 on 1/4/25. The facility failed to prevent this abuse and failed to implement effective dementia care interventions to prevent Resident #1 from wandering into other residents' rooms.
Findings
The facility failed to protect Resident #1 from sexual abuse by Resident #2 and failed to provide appropriate dementia care interventions to prevent Resident #1 from wandering into other residents' rooms. The sexual abuse was substantiated and the facility's dementia management interventions were ineffective.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from sexual abuse by Resident #2, resulting in minimal harm or potential for actual harm.
F 0744: The facility failed to provide appropriate treatment and services to Resident #1 with dementia to maintain her highest practicable well-being, including ineffective interventions to prevent wandering.
Report Facts
Residents affected: 1
Resident sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding knowledge of Resident #1 and Resident #2 |
| Certified Nurse Aide #2 | CNA | Interviewed about Resident #1's wandering and behavior |
| Licensed Practical Nurse #2 | Unit Manager | Interviewed about Resident #1 and Resident #2's supervision and monitoring |
| Nursing Home Administrator | NHA | Interviewed about Resident #2's history of sexually inappropriate behavior and facility interventions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to investigate allegations of abuse, neglect, and failure to report and investigate incidents of potential abuse involving residents at the facility.
Complaint Details
The complaint investigation substantiated that physical abuse occurred between Resident #2 and Resident #3 on 3/21/24. The facility failed to report and investigate two incidents of potential sexual abuse involving Resident #2 and Resident #8 occurring on 9/14/24 and 9/17/24. The facility reported these incidents to the State Agency during the survey and initiated investigations and corrective actions.
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 conduct investigations of potential sexual abuse incidents involving residents. The facility acknowledged these failures and initiated corrective actions during the survey.
Deficiencies (3)
F0600: The facility failed to protect residents from abuse, specifically failing to prevent physical abuse between Resident #2 and Resident #3 on 3/21/24.
F0609: The facility failed to timely report two incidents of potential sexual abuse involving Resident #2 and Resident #8 to the State Agency as required by law.
F0610: The facility failed to investigate incidents of potential sexual abuse involving Resident #2 and Resident #8, and failed to respond appropriately to all alleged violations.
Report Facts
Sample residents reviewed: 9
Residents reviewed for abuse: 5
Residents affected: 2
Residents affected: 2
BIMS score: 3
BIMS score: 4
Hematoma size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed as abuse coordinator and responsible for directing abuse investigations | |
| Regional Clinical Consultant (RCC) | Interviewed regarding facility's performance improvement plan and abuse investigation processes |
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
Complaint Investigation
Deficiencies: 1
Date: May 21, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate treatment and care to residents, specifically concerning wound care and skin assessments.
Complaint Details
The complaint investigation found that the facility did not properly manage skin injuries for Resident #3, including incomplete skin assessments, lack of documentation and notification to physician or family, and failure to implement preventive measures such as knee pads which the resident refused. The Director of Nursing acknowledged these issues and initiated a performance improvement plan.
Findings
The facility failed to ensure one resident received treatment and care according to professional standards, including failure to investigate and prevent wounds on the resident's knees and to complete routine weekly skin assessments. Documentation and notification of injuries were also lacking.
Deficiencies (1)
F 0684: The facility failed to investigate, treat, and implement interventions to prevent wounds to Resident #3's knees and did not complete routine weekly skin assessments as ordered.
Report Facts
Sample residents reviewed: 15
Residents affected: 3
Skin assessment dates missed: 1
Skin scab sizes: 1
Skin abrasion size: 2
Nursing management audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Observed Resident #3 and reported concerns about knee injuries | |
| Unit Manager #1 | Interviewed about awareness of Resident #3's knee injuries | |
| Director of Nursing | Interviewed regarding Resident #3's care, acknowledged failures, and provided performance improvement plan |
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
Complaint Investigation
Deficiencies: 1
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the failure to provide meaningful activities designed to support residents' physical, mental, and psychosocial well-being at Boulder Post Acute.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to provide meaningful activities for residents #100, #92, #97, and #70. Residents reported lack of activities, inadequate staffing, and lack of communication about activities. The facility acknowledged a staffing crisis and limited outings due to staff shortages.
Findings
The facility failed to provide meaningful activities, including activities of personal choice, for four of six sampled residents. Staffing shortages and lack of communication about activities contributed to residents not participating or being unaware of scheduled activities.
Deficiencies (1)
F 0679: The facility failed to provide meaningful activities to meet all residents' needs, affecting four residents. Activity staff shortages and lack of invitations to activities were noted.
Report Facts
Sample residents: 42
Residents affected: 4
BIMS scores: 3
BIMS scores: 15
BIMS scores: 15
BIMS scores: 11
Activity frequency: 2
One-on-one activities: 1
One-on-one activities: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Interviewed regarding activity scheduling, staffing shortages, and outings | |
| Certified Nurse Aide #5 | Interviewed; did not inform Resident #70 of Bingo game | |
| Licensed Practical Nurse #3 | Interviewed; described activity staff handing out chronicle and snacks | |
| Certified Nurse Aide #6 | Interviewed; observed limited activity staff engagement | |
| Licensed Practical Nurse #1 | Interviewed; described Resident #92 and Resident #97 activity participation and needs | |
| Activities Assistant #1 | Mentioned by Activity Director as helping cover weekend activities |
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: 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 for several residents, and failed to properly label and store food in nourishment refrigerators, including staff storing personal food in resident refrigerators.
Deficiencies (3)
F 0644: The facility failed to arrange and incorporate PASRR level II recommendations for Resident #63 with serious mental illness, including psychiatric case consultation and behavior management.
F 0679: The facility failed to provide meaningful activities tailored to residents' preferences for four residents (#100, #92, #97, and #70), including lack of notification about activities and insufficient activity staff coverage.
F 0812: The facility failed to ensure food was labeled and dated in nourishment rooms and allowed staff to store personal food in resident nourishment refrigerators on multiple floors.
Report Facts
Residents reviewed for PASRR: 42
Residents affected by PASRR deficiency: 1
Residents affected by activity deficiency: 4
Residents in activity sample: 42
Food storage locations with deficiencies: 3
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 about psychiatric care and therapy referrals for Resident #63 |
| Director of Nursing | DON | Interviewed about PASRR process and activity program oversight |
| Certified Nurse Aide #5 | CNA | Interviewed about failure to inform Resident #70 of Bingo activity |
| Licensed Practical Nurse #3 | LPN | Interviewed about activity staff handing out daily chronicle and snacks |
| Certified Nurse Aide #6 | CNA | Interviewed about activity staff presence and cancellations |
| Activity Director | AD | Interviewed about activity scheduling, staffing, and resident participation |
| Licensed Practical Nurse #1 | LPN | Interviewed about Resident #92's activity participation and vision impairment |
| Nurse Manager #1 | NM | Interviewed about nourishment refrigerator food items and labeling |
| Certified Nurse Aide #2 | CNA | Interviewed about staff storing personal food in nourishment refrigerators |
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
Deficiencies: 12
Date: Dec 1, 2022
Visit Reason
Routine state inspection of Boulder Post Acute nursing home to assess compliance with regulatory requirements including resident rights, environment, grievance handling, discharge planning, activities, nutrition, infection control, and COVID-19 vaccination and testing.
Findings
The facility was cited for multiple deficiencies including failure to honor residents' rights regarding advance directives, maintain comfortable temperatures, resolve grievances promptly, complete discharge summaries, provide adequate personal care and activities, serve palatable and nutritious food, maintain sanitary food preparation areas, ensure safe food storage, implement infection control practices including hand hygiene and COVID-19 testing protocols, and ensure staff COVID-19 vaccination compliance.
Deficiencies (12)
F0578: The facility failed to ensure Resident #99 and Resident #11's advance directives matched physician orders, violating residents' rights to formulate advance directives.
F0584: The facility failed to maintain comfortable room temperatures on Units #1, #2, and #4, with observed temperatures below the facility's policy range of 71-81°F.
F0585: The facility failed to provide prompt resolution to Resident #89's grievances regarding shower chair, catheter locks, and cranberry pills, with no grievance forms documented.
F0661: The facility failed to provide a complete discharge summary for Resident #144, omitting key clinical and care information necessary for safe transition.
F0677: The facility failed to provide necessary care for activities of daily living for Residents #99, #11, and #77, including regular showers and nail care.
F0679: The facility failed to provide activities meeting Resident #89's interests, lacking one-on-one programming and documentation of participation or refusals.
F0804: The facility failed to serve palatable food and meet nutritional needs, with complaints of salty, overcooked, and unappetizing food, missing menu items, and inadequate protein for vegetarians.
F0812: The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including unlabeled and undated foods in main and unit refrigerators, unclean kitchen and unit refrigerators, uncovered trash, improper food cooling, and unrepaired holes in kitchen walls.
F0813: The facility failed to implement policy for safe storage and monitoring of foods brought by visitors in residents' personal refrigerators, lacking labeling, temperature monitoring, and cleaning documentation.
F0880: The facility failed to provide and encourage hand hygiene to residents at meal times and staff failed to follow proper hand hygiene during meal assistance on multiple units.
F0886: The facility failed to properly disinfect the COVID-19 testing area between staff tests, lacked cleaning supplies and signage, and allowed shared use of a public bathroom during testing.
F0888: The facility failed to develop and implement a COVID-19 staff vaccination process ensuring all staff, including agency and contracted providers, were vaccinated or exempt, allowing unvaccinated staff to work without exemption or delay.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 4
Staff shifts worked: 24
COVID-19 positive residents: 5
COVID-19 positive staff: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in Resident #48 care concerns and vaccination status discrepancy |
| CNA #5 | Certified Nursing Aide | Worked over six months without full COVID vaccination |
| DA #1 | Dietary Aide | Worked over one month without full COVID vaccination |
| CNA #4 | Certified Nursing Aide | Vaccination status discrepancy |
| CNA #6 | Certified Nursing Aide | Vaccination status discrepancy |
| NP #1 | Nurse Practitioner | Provider not listed on vaccination matrix |
| MD #1 | Medical Doctor | Provider not listed on vaccination matrix |
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 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 19, 2021
Visit Reason
Annual inspection of Boulder Post Acute nursing home to assess compliance with regulatory requirements including resident care, abuse prevention, food service, infection control, and safety.
Findings
The facility failed to prevent resident-to-resident abuse and altercations among residents with dementia, failed to keep resident property safe, did not provide adequate dementia care with personalized interventions, served food that lacked flavor and proper temperature, failed to maintain sanitary food service and refrigerator cleanliness, and did not ensure proper infection control cleaning procedures.
Deficiencies (6)
F600: The facility failed to protect residents from abuse by not preventing physical altercations among residents with dementia, resulting in minimal harm or potential for harm.
F602: The facility failed to prevent misappropriation of Resident #111's four wedding rings and did not maintain proper inventory or secure storage.
F744: The facility failed to provide appropriate dementia care including personalized care plans, non-pharmacological interventions, and meaningful activities to prevent resident distress and altercations.
F804: The facility failed to ensure food was palatable, attractive, and served at safe temperatures, with meals lacking flavor and proper texture, and some food served cold or burnt.
F812: The facility failed to follow sanitary food service procedures, maintain and clean satellite refrigerators, and document food temperatures during meal service.
F880: The facility failed to maintain an infection control program by not cleaning high-touch surfaces and bathrooms properly, including improper use of toilet brushes and failure to clean from clean to dirty.
Report Facts
Behavioral episodes: 19
Behavioral episodes: 24
Behavioral episodes: 19
Facility census: 136
Residents with dementia: 50
Residents with psychiatric diagnosis: 57
Residents with behavioral healthcare needs: 67
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