Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Post Acute during CMS and state inspections, most recent first.
Improper Hand Hygiene and Glove Use During Meal Service: A cook was observed plating and serving food in the main kitchen with bare hands and gloves used inconsistently during meal service. He handled ready-to-eat items, including hot dogs, buns, and grilled cheese sandwiches, without hand hygiene before donning gloves and continued using the same gloved hands to touch multiple foods and utensils. The DM stated staff were expected to wash hands before and after glove use and to discard gloves after single use.
The facility failed to ensure that medications in two medication carts were properly labeled with open dates. An LPN observed two vials of haloperidol deconate without open dates and one Spiriva inhaler without an open date on one cart, and another LPN observed two more haloperidol deconate vials plus Spiriva Respimat and Stiolto Respimat inhalers without open dates on another cart. The LPNs and DON stated open dates are needed to track expiration and effectiveness.
The facility failed to follow orders for two residents. One resident with severe cognitive impairment had a midline catheter dressing left unchanged beyond the expected interval, and the order for dressing changes was not entered until after the catheter had already been in place for days. Another resident with dementia and diabetes had repeated blood glucose readings in the range for ordered sliding scale Lispro, but the MAR showed no doses were administered and staff did not clarify the order despite multiple elevated readings.
A resident with a G tube, dementia, dysphagia, epilepsy, and malnutrition was ordered continuous Iso-source 1.5 via pump with scheduled water flushes, but nursing staff gave multiple PRN bolus feedings when the pump volume was behind. The chart did not show a physician order for the boluses or notification to the PCP or RD before they were given, and staff interviews confirmed the boluses were based on their own calculations and family requests rather than the ordered feeding plan.
Mechanically altered diets were not prepared as ordered for three residents. One resident with dementia and malnutrition received meatballs and noodles that were too large for a soft and bite-sized diet, while two other residents with dysphagia were served broccoli, noodles, and a protein drink that did not match the ordered texture or thickened-liquid requirements. Staff interviews showed inconsistent understanding of IDDSI diet standards and inappropriate snack choices for altered diets.
Staff failed to follow infection control practices during resident care and environmental cleaning. A CNA assisted dependent residents with eating and moved between residents without performing hand hygiene, staff entered a resident’s room under contact/EBP precautions without donning the required gown and gloves, and a housekeeper wiped disinfectant from surfaces before the required dwell time, reused a cleaning rag after it fell on the floor, and cleaned the toilet out of sequence.
A resident with dementia and a known risk for elopement was not properly monitored with required 15-minute safety checks, and staff failed to respond appropriately to a door alarm when the resident exited the building. The resident was missing for approximately 12 hours before being found by police, after staff did not discover the absence or notify facility leadership in a timely manner.
Two residents with cognitive and behavioral health issues engaged in a physical altercation after one, experiencing increased agitation and recent medication changes, attempted to strike the other. The second resident responded physically, leading to both falling and sustaining injuries, including a shoulder fracture. Staff were not present in the dining room at the time, and prior behavioral warning signs were documented but not adequately addressed to prevent the incident.
A resident with severe cognitive impairments wandered into another resident's room and was sexually abused by a resident with a history of inappropriate behaviors. The facility failed to maintain necessary supervision, allowing the incident to occur despite known risks.
A facility failed to provide appropriate dementia care for a resident, leading to her wandering into other residents' rooms. Despite being on a care plan with interventions like 15-minute checks, the resident, diagnosed with dementia, was found sleeping in other rooms multiple times. Staff interviews and observations indicated a lack of person-centered interventions and room identification aids, contributing to the deficiency.
Two residents with cognitive impairments were involved in a physical altercation, resulting in injuries. The facility failed to prevent the incident and initially did not substantiate the abuse due to lack of witnesses, despite injuries consistent with the residents' accounts. The care plans for both residents, which included supervision and behavior management, were not effectively implemented.
Two residents with cognitive impairments were involved in incidents of potential sexual abuse that were not reported to the State Agency as required. The facility's policy mandates reporting all alleged violations, but these incidents were neither investigated nor reported. Staff confirmed the reporting failure during interviews.
The facility failed to investigate two incidents of potential sexual abuse involving a resident with severe cognitive impairment and inappropriate behavior towards another resident with communication deficits. Despite documentation of these incidents, no investigations were conducted, contrary to facility policy requiring immediate investigation of abuse reports.
The facility failed to investigate, treat, or implement interventions to prevent a resident's knee wounds and did not complete routine weekly skin assessments. The resident, with Huntington's disease and a history of falls, had multiple scabbed and abraded areas on both knees. The care plan did not include measures to prevent knee injuries, and there was no documentation of the injuries or notification to the physician, resident, or MDPOA.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
Food was not handled in a sanitary manner in the main kitchen during meal service. A cook was observed plating food with utensils while using bare hands, then putting on gloves without first performing hand hygiene and slicing a hot dog to place on a bun. After removing those gloves, he returned to serving food with utensils without washing his hands. He then put on another pair of gloves without hand hygiene, cut another hot dog, and removed a bun from the bag the buns came in. During the same meal service, the cook continued using the same gloved hands to pick up four grilled cheese sandwiches and to serve food with utensils. He also used the same gloved hands to pull hot dog buns from their bag, open them, and plate the food. The dietary manager stated that staff were expected to wash their hands before and after putting on gloves and to remove gloves after single use, and said she had provided in-services on single-use gloves and hand hygiene since starting three weeks earlier.
Unlabeled Open Dates on Medications in Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of six medication carts. During observation of the second floor medication cart with an LPN, two vials of haloperidol deconate 500 mg/5 ml for injection were found without the date they were opened, and one Spiriva inhaler was also not marked with an open date. During observation of the east third floor medication cart with another LPN, two additional vials of haloperidol deconate 500 mg/5 ml for injection were not marked with the date they were opened, along with one Spiriva Respimat inhaler and one Stiolto Respimat inhaler that were not marked with open dates. The LPNs stated that open dates are needed to know when the medications expire and remain effective, and the DON stated that open dates must be marked to ensure medications were not expired and remained effective.
Failure to Follow Orders for Midline Dressing Care and Sliding Scale Insulin
Penalty
Summary
The facility failed to provide treatment and care according to orders and professional standards for two residents. One resident had a midline catheter placed for IV fluids and, although the transparent dressing was dated the day the catheter was inserted, the dressing was still in place 10 days later when an LPN changed it during the survey. The resident had severe cognitive impairment, was dependent on staff for all ADLs, and the record did not contain a physician order for the midline dressing change until 11 days after the catheter was placed. The DON and regional clinical resource stated the standard of practice for a transparent dressing change was every seven days and as needed, and the DON acknowledged the dressing should have been changed seven days after placement and that the order should have been entered into the EMR. The facility also failed to follow physician orders for another resident’s sliding scale insulin. The resident had dementia with behavioral disturbance, type 2 diabetes with hyperglycemia, and long-term insulin use. The physician’s orders included Lispro insulin on a sliding scale for blood glucose readings in specified ranges, along with scheduled Glargine insulin and blood glucose monitoring. Review of the MAR from October 2025 through February 2026 did not show any administered doses of the sliding scale Lispro insulin, despite multiple progress notes documenting blood glucose readings in the ordered treatment range. Those progress notes showed repeated elevated blood glucose values, including readings in the 300s, but the corresponding sliding scale insulin doses were not given. Staff interviews showed mixed understanding of the insulin orders: one LPN said the facility did not use sliding scale insulin and would clarify such orders, while the DON said the facility tried to avoid sliding scale insulin but nursing staff should follow the order if present. The resident’s PCP said he expected the nursing staff to follow the orders or contact him with questions, and the record did not show communication to clarify the sliding scale order before it was later discontinued during the survey.
Feeding Tube Orders Not Followed
Penalty
Summary
The facility failed to ensure a resident with a feeding tube received tube feedings according to physician's orders. The resident had a gastrostomy tube and diagnoses including epilepsy, Alzheimer's disease, dysphagia, malnutrition, dementia, and celiac disease. The resident's care plan called for enteral nutrition as ordered, monitoring tolerance, flushing the G tube, elevating the head of bed, and reporting significant changes to the physician and RD. The physician's orders directed continuous Iso-source 1.5 tube feeding through a pump at specified rates and times, with scheduled free water flushes. Nursing documentation showed that staff repeatedly gave additional bolus feedings when the resident did not receive the full calculated amount during the continuous feeding period. On one occasion, an RN documented giving a bolus because the pump volume was behind; on another, a nurse gave a bolus to total the ordered daily volume; and on another, a nurse gave an additional bolus during a pause in feeding for changes and repositioning, after which the resident began coughing and became nauseous. The family refused further bolus feedings at that time. The record did not show a physician's order for PRN bolus feedings, and the notes did not document that the physician or RD had been notified before the boluses were given. Interviews confirmed that staff calculated and administered bolus feedings on their own because the resident was not receiving the full amount during the continuous schedule. The PCP stated he was aware of the bolus feedings after they were given and that he expected staff to follow the continuous feeding orders. The RD stated she would have expected a physician's order for bolus feedings and to be notified so she could reassess the resident, but she was not notified until days later.
Mechanically Altered Diets Not Prepared as Ordered
Penalty
Summary
The facility failed to ensure that residents with mechanically altered diet orders received food prepared in the form ordered. The deficiency involved three residents who were prescribed altered textures and, in one case, thickened liquids, but were observed receiving foods and drinks that did not match the ordered consistency or size requirements. The report cites IDDSI guidance and the facility’s therapeutic diet policy, which required diet orders to match the terminology used by food and nutrition services and for mechanically altered diets to be prepared according to the specified texture modification. One resident with dementia, protein-calorie malnutrition, generalized muscle weakness, and palliative care status was ordered a regular diet with level 6 soft and bite-sized texture and thin liquids. During observation, the resident was served a lunch tray with meatballs about 1.5 inches in diameter and noodles approximately 1.5 to 2 inches long, and later could not bite into a meatball that dropped into the resident’s lap and onto the floor. Staff interviews showed inconsistent understanding of diet textures, with some staff describing inappropriate snacks such as saltine crackers for residents on altered diets. The RD stated that food for this resident should have been cut to the IDDSI-recommended size. Another resident with neurocognitive disorder with Lewy bodies and dysphagia was ordered a regular diet with soft and bite-sized texture and mildly thick liquids. The resident was observed receiving chopped broccoli that did not meet the IDDSI size recommendation and regular-size noodles. The resident was also offered a protein drink that was not thickened. A third resident with weakness on the right dominant side and dysphagia was ordered a regular diet with level 5 minced and moist texture and mildly thick liquids, but was observed receiving chopped broccoli that did not meet the IDDSI size recommendation. The report also states that protein drinks provided to these residents were not consistent with mildly thick liquid requirements, and the manufacturer’s information indicated the products did not meet level 2 mildly thick criteria.
Infection Control Failures During Hand Hygiene, PPE Use, and Room Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in multiple areas. During meal service, a CNA was observed assisting dependent residents with eating and moving between residents without performing hand hygiene between resident contacts, after wiping a resident’s mouth, or before returning to assist another resident. The facility’s hand hygiene policy stated that hand hygiene should be performed between resident contacts and after assistance with personal body functions, and the infection preventionist stated staff should perform hand hygiene after assisting each resident before moving to the next resident. The facility also failed to ensure staff used the required PPE when entering a resident’s room under transmission-based precautions. The door sign instructed staff to wear gloves and a gown before entering, but a CNA entered the room without PPE, an RN entered without PPE while carrying a large syringe containing red liquid, and the CNA later re-entered the room with linens without donning a gown or gloves. The RN stated she did not read the sign, and the CNA stated she put PPE on inside the room. The resident was described by staff as being on contact precautions for MDROs in the urine and also on enhanced barrier precautions because of indwelling devices including a midline catheter and a gastrostomy tube. Housekeeping practices were also observed to be inconsistent with infection control guidance. A housekeeper sprayed disinfectant on a door knob, door, and sink and immediately wiped the surfaces instead of allowing the disinfectant dwell time. The housekeeper dropped a cleaning rag on the floor and continued using it, and she cleaned the toilet in a sequence that did not follow cleaner-to-dirtier practice. The infection preventionist and corporate maintenance director both stated the housekeeper should have followed proper cleaning sequence and dwell time requirements.
Failure to Supervise and Respond to Elopement Risk
Penalty
Summary
A deficiency occurred when staff failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident at risk for elopement. The resident, who had a diagnosis of frontal temporal neurocognitive disorder and was assessed as an elopement risk, was supposed to be monitored with 15-minute safety checks due to inappropriate behaviors. On the night in question, the assigned CNAs and LPN did not perform or document these checks as required by facility protocol. Video surveillance later confirmed that the checks were not conducted, despite documentation indicating otherwise. At approximately 8:14 p.m., the resident exited the facility by riding the elevator from the fourth floor to the first floor, opening the front door, and leaving the building. The door alarm was triggered, but the staff member who heard the alarm only looked out a window, did not see anyone, and failed to search the area or notify others. The alarm was reset without further investigation. The absence of the resident was not discovered until nearly eight hours later, at around 4:00 a.m., when a CNA noticed the resident was missing. The LPN was notified, but the NHA was not informed until over two hours after the resident was found to be missing. The resident was found by police approximately 12 hours after leaving the facility, sitting on a curb in a neighborhood, confused and unable to recall the events during his absence. The resident was taken to a hospital for evaluation and was found to have no injuries. The failure to conduct required safety checks and to respond appropriately to the door alarm directly led to the resident's elopement and prolonged absence from the facility.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, resulting in both sustaining injuries. On the date of the incident, one resident with severe cognitive impairment and a history of bipolar disorder and alcohol-induced persisting dementia, who had recently experienced a gradual dose reduction and discontinuation of Zyprexa, exhibited increased agitation and aggressive behaviors. Despite documented behavioral changes and staff observations of escalating agitation, the resident was only restarted on Zyprexa two days prior to the altercation, which was not sufficient time for the medication to take effect. The second resident involved was cognitively intact but had diagnoses including alcohol-induced persisting dementia, anxiety disorder, and delusional disorder. This resident had a history of delusions and agitation toward others, as documented in the care plan. On the day of the incident, the first resident entered the dining room, displayed agitated behavior, and attempted to strike the second resident. In response, the second resident physically engaged with the first, resulting in both falling to the ground. The second resident sustained a left humerus fracture requiring medical intervention, while the first resident suffered bruising and an abrasion. Staff were not present in the dining room at the time of the altercation, and the incident was only discovered after a nurse heard noise and investigated. Prior to the event, there were multiple documented instances of the first resident's increased agitation and behavioral disturbances, including throwing furniture and being difficult to redirect. Despite these warning signs, there was no evidence of increased supervision or intervention to prevent resident-to-resident altercations, and both residents had no prior history of physical altercations with each other.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident occurred when a resident with severe cognitive impairments wandered into another resident's room and fell asleep on a bed. The resident who was the assailant, also with severe cognitive impairments and a history of sexually inappropriate behaviors, returned to his room and touched the sleeping resident in a sexual manner. This incident was discovered by a certified nurse aide who immediately separated the residents. The assailant resident had been previously identified with sexually inappropriate behaviors and was on a behavioral care plan that included one-to-one supervision. However, at the time of the incident, the resident was not under one-to-one supervision, as his behaviors had reportedly improved after medication adjustments. The facility's failure to maintain the necessary supervision allowed the incident to occur, despite the known risks associated with the resident's behavior. The victim resident, also with severe cognitive impairments, was known to wander and occasionally enter other residents' rooms. Staff were aware of this behavior and checked on her every 15 minutes. However, the facility's measures were insufficient to prevent the incident, as the resident was able to enter another resident's room and fall asleep without being noticed until the inappropriate contact occurred.
Failure to Implement Effective Dementia Management Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in the resident wandering into other residents' rooms. The resident, a 72-year-old with severe cognitive impairments and a diagnosis of dementia with behavioral disturbance, was admitted to the facility and required supervision and minimal assistance with activities of daily living. Despite being on a behavioral care plan that included interventions such as maintaining a calm approach and checking on the resident every 15 minutes, the resident was found sleeping in other residents' rooms on multiple occasions. The care plan did not include person-centered dementia interventions to prevent such incidents. Observations and staff interviews revealed that the resident's room lacked personal items or signs to help her identify it, contributing to her wandering behavior. Staff, including an agency nurse and CNAs, were aware of the resident's tendency to wander and occasionally enter other residents' rooms. However, the interventions in place, such as 15-minute checks, were not effective in preventing these occurrences. The facility's failure to implement effective dementia management interventions led to the resident being found in other residents' rooms, highlighting a deficiency in the care provided to maintain the resident's highest practicable well-being.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically failing to prevent an altercation between them. The incident involved Resident #2 and Resident #3, where Resident #2 reported being pushed by Resident #3, resulting in a fall and a head injury. Resident #3 claimed that Resident #2 had entered his room and punched him, prompting Resident #3 to push Resident #2 in self-defense. Both residents sustained injuries consistent with their accounts, yet the facility initially deemed the abuse unsubstantiated due to the lack of a witness. Resident #2, under the age of 65, was diagnosed with dementia and cognitive communication deficit, exhibiting severe cognitive impairment. His care plan included measures for managing sexually inappropriate behaviors and required one-to-one supervision. Despite these interventions, Resident #2 was involved in the altercation with Resident #3, indicating a lapse in supervision and care plan implementation. Resident #3, aged 68, had a history of moderate cognitive impairment and episodes of physical aggression when feeling his personal space was invaded. His care plan included monitoring and reporting aggressive behaviors and maintaining a calm approach. The incident with Resident #2 suggests that these interventions were not effectively implemented, leading to the physical altercation. The facility's failure to substantiate the abuse initially was later acknowledged as an oversight by the nursing home administrator.
Failure to Report Potential Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency as required by state law. Specifically, two incidents of potential sexual abuse involving two residents were not reported. The facility's policy mandates that all alleged violations, including abuse, neglect, and exploitation, must be reported to the administrator, state agency, and other required agencies within specified time frames. However, the facility did not adhere to this policy in the cases of the two residents. The first resident, who was under 65 and diagnosed with dementia and cognitive communication deficit, exhibited sexually inappropriate behaviors. Despite having a care plan that included one-to-one supervision and other interventions, the resident was involved in incidents where he inappropriately touched another resident. These incidents were documented in nursing progress notes but were not investigated or reported to the State Agency as potential sexual abuse. The second resident, also under 65, had diagnoses including bipolar disorder and dementia with psychotic disturbance. She was dependent on staff for all activities of daily living and had impaired memory and decision-making skills. The incidents involving this resident included inappropriate touching by the first resident, which were observed by staff but not reported or investigated as potential abuse. Interviews with facility staff confirmed that these incidents should have been reported, but they were not until the survey was conducted.
Failure to Investigate Potential Abuse Incidents
Penalty
Summary
The facility failed to investigate incidents of potential sexual abuse involving two residents, which were identified during a survey. The facility's policy requires immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the facility did not conduct investigations for two incidents involving inappropriate behavior by one resident towards another. The first incident occurred when a resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed holding and kissing the hands of another resident with severe cognitive and communication deficits. This incident was documented in a nurse's progress note, but no investigation was conducted at the time. The second incident involved the same resident holding and rubbing the hand of the same resident, despite attempts by staff to redirect him. Again, no investigation was conducted following this incident. Interviews with facility staff revealed that the incidents should have been investigated, but were not. The facility's regional clinical consultant acknowledged that there was an issue with staff understanding of what constitutes abuse and the investigation process. Despite recognizing these issues, the facility did not complete the required investigations for the incidents involving the two residents.
Failure to Prevent and Document Resident's Knee Injuries
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not investigate, treat, or implement interventions to prevent wounds on the resident's knees. The resident, who had Huntington's disease and a history of falls, was observed with multiple scabbed and abraded areas on both knees. The certified nurse aide (CNA) and unit manager were aware of the injuries but did not know the plan to prevent them. The resident's care plan did not include measures to prevent knee injuries, and there was no documentation of the injuries in the resident's progress notes or evaluations. The facility also failed to complete routine weekly skin assessments for the resident. The skin assessment for one week was incomplete, and there was no assessment for another week. The director of nursing (DON) acknowledged that the resident's knee injuries were not documented, and the physician, resident, or medical durable power of attorney (MDPOA) were not notified. Additionally, the DON admitted that the resident was supposed to wear knee pads to prevent injuries, but there was no documentation that knee pads had been offered and refused. The facility's policies for skin management and accidents and injuries were requested but not provided by the end of the survey. The DON also noted that there were four residents who had missed skin assessments, indicating a broader issue with the facility's skin assessment process. The lack of documentation and failure to follow the care plan and professional standards of practice led to the deficiency identified in the survey.
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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 Boulder
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winding Trails Post Acute | 1.4 mi | ★★★★★ | 4 | 0 |
| Boulder Canyon Health And Rehabilitation | 2.3 mi | ★★★★★ | 6 | 0 |
| Frasier Meadows Health Care Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Coal Creek Post Acute & Assisted Living | 10.2 mi | ★★★★★ | 14 | 0 |
| Accel At Longmont Health And Rehab, Llc | 10.2 mi | ★★★★★ | 47 | 1 |
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