Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Frasier Meadows Health Care Center during CMS and state inspections, most recent first.
Kitchen Sanitation and Food Storage Deficiencies: Surveyors observed food debris, crumbs, residue, and improperly stored items in the main kitchen and a satellite kitchen, including items on the floor and beneath shelving and equipment. Surveyors also found expired, uncovered, and unlabeled food in refrigeration areas, including sauces, salmon, vegetables, beef, pork sauce, sweet potatoes, and cheese past its good-through date. Staff stated that food and kitchen areas should be kept clean, and prepared foods should be covered, labeled, and dated before storage.
The facility failed to protect residents’ rights related to binding arbitration agreements for three residents reviewed. The admission agreement did not inform residents or their representatives of the right to revoke the agreement within 30 days, and the DON confirmed the current agreement lacked that required language. The DON stated she explained the agreement on admission, but acknowledged she did not realize the 30-day stipulation had to be included.
Failure to Ensure Annual Dementia Training for CNAs: The facility did not ensure CNAs received required annual in-service training that included dementia management. Record review showed multiple CNAs had not completed dementia-specific training within the expected timeframe, and staff interviews confirmed uncertainty about when training was last completed. The NHA said the issue had been recognized in QAPI meetings, but funding for training was being delayed until the new fiscal year.
Failure to Monitor Air Mattress for a Resident with a Pressure Ulcer: A resident with dementia, dependence for ADLs, and a stage 3 pressure ulcer was observed on an air mattress that was on and set to alternate, but the EMR did not document the mattress settings. The care plan did not include the air mattress as an intervention, the CPO lacked orders for the settings, and the MAR/TAR did not show regular checks of the mattress function. Staff interviews showed nurses were expected to monitor the mattress, but there was no set schedule, and a nursing note linked a new lower-back pressure injury to air mattress failure.
Respiratory care was not provided consistently for two residents. One resident’s BiPAP mask was observed with residue and moisture, while the care plan and EMR lacked cleaning and storage interventions and staff gave conflicting accounts of who cleaned the equipment and how often. Another resident had active CPAP orders, but the CPAP was observed with dust buildup, staff documentation was unclear about whether the device was refused or not used, and the oxygen order did not specify a flow rate even though staff were using oxygen and titrating it to keep SpO2 above 90%.
A resident at risk for pressure injuries developed severe heel blisters due to the facility's delayed implementation of appropriate interventions. Despite initial measures like a pressure-reducing mattress, heel booties and an air mattress overlay were only used after the blisters appeared, leading to the resident's discharge to the hospital for further treatment.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and one satellite kitchen. During the initial tour, surveyors observed food debris beneath storage shelving in the satellite kitchen dry storage area, along with several individual packages of peanut butter on the floor beneath the shelving. In the main kitchen, surveyors observed accumulations of food debris and crumbs beneath a work table and adjacent shelving, two cans of Sprite on the floor under shelving, and a dark brown unidentified residue beneath the oven with additional food particles and crumbs near the cooking equipment. A second observation of the kitchen identified the same sanitation concerns. Staff interviews indicated that cooks and dietary management were responsible for cleaning floors, shelves, work tables, and areas underneath equipment, and they stated that these areas should be swept daily and kept free of food debris, residue, and improperly stored items. The dietary manager stated that failure to keep these areas clean could lead to cross-contamination and sanitation concerns. The facility also failed to properly cover, label, date, and discard food items in storage. In the satellite kitchen walk-in refrigerator, a package of Swiss cheese had a good-through date that had already passed. In the main kitchen refrigerator and walk-in refrigerator, surveyors observed uncovered pans of hoisin sauce, pork sauce, and sun-dried tomato sauce, a pan of salmon covered with plastic wrap but without a date or label, a pan of cut vegetables without a cover or date label, a pan of beef without a cover, a pan of pork sauce without a cover or wrap, and a container of peeled sweet potatoes soaked in water without a label or preparation date. These same concerns were still present on later observations. Staff stated that prepared foods should be labeled, dated, and covered before storage, and that food without a preparation date or discard date should be discarded if the date could not be determined.
Failure to Inform Residents of Arbitration Revocation Rights
Penalty
Summary
The facility failed to protect residents’ rights regarding binding arbitration agreements for three residents reviewed out of a sample of 27. Record review showed that the admission agreement and Binding Arbitration Agreement, revised January 2025, did not inform the resident or the resident’s representative of the right to revoke the agreement within 30 calendar days of signing. The facility also did not provide its arbitration policy when requested during the survey. Contract review showed that the representatives for three residents signed the arbitration agreement on separate dates, but the agreement did not include language informing the resident or representative of the right to rescind the agreement within 30 days. During interview, the DON, who was temporarily acting as the admission coordinator, stated there were no additional documents regarding the arbitration agreements and confirmed the revised agreement was the most current version. She said she explained the agreement to residents and representatives on admission, but acknowledged she did not realize the 30-day stipulation needed to be included in the contract.
Failure to Ensure Annual Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure certified nurse aides received at least 12 hours of annual in-service training that included dementia management training. Record review showed that CNA #5, hired on 11/27/23, last completed dementia-specific training on 12/31/23; CNA #8, hired on 3/07/11, last completed it on 10/17/24; CNA #9, hired on 2/14/06, last completed it on 11/18/24; CNA #10, hired on 11/9/11, last completed it on 6/21/24; and CNA #11, hired on 11/23/11, last completed it on 4/6/24. The facility did not have a system in place to ensure these CNAs received annual dementia training. During interviews, CNA #12 said she had been trained on managing individuals with dementia but did not remember when she last completed the dementia-specific training, and her online training showed completion in 2024. CNA #6 said he did not remember when he last completed dementia training. CNA #5 said she believed she had completed dementia-specific training annually and thought it may have been in September or December 2025, but the documentation showed her last completion was 12/31/23. The NHA stated the facility recognized the need for training and discussed it in QAPI meetings, but said they were waiting until the new fiscal year in July 2026 to secure funding for training.
Failure to Monitor Air Mattress Settings for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a pressure ulcer by not having physician’s orders documented for the settings of the resident’s air mattress and by not regularly checking the mattress function. The resident had diagnoses including Alzheimer’s disease, dementia, muscle wasting and atrophy, hypertension, a history of urinary tract infections, and long-term anticoagulant use. The resident was dependent on staff for multiple activities of daily living and was identified by the MDS as being at risk for pressure injuries, with one stage 3 pressure ulcer and a pressure-reducing device in use for both the chair and bed. On observation, the resident was lying in bed on an air mattress that was in the ON position and set to alternate, but the EMR did not show the mattress settings. The care plan addressed skin breakdown risk and included interventions such as frequent turning and repositioning, skin inspection, and keeping linens dry and wrinkle free, but it did not include the air mattress as an intervention or identify its settings. Review of the EMR, MAR, and TAR did not show documentation that staff regularly checked the function or settings of the air mattress, and the June 2026 CPO did not contain physician’s orders for the mattress settings. The record also showed a nursing note stating the resident developed a new pressure injury to the lower back related to air mattress failure. The EMR did not show documentation that staff checked on the resident every two hours on the day the mattress failed. Staff interviews indicated nurses were expected to check the mattress when entering the room, but one RN did not know the prescribed setting, CNAs said nurses were responsible for monitoring the mattress, and the central supply coordinator said he set up the mattress but did not monitor it continuously. The NHA and DON acknowledged the mattress should have been monitored and maintained according to policy, and the DON stated the care plan and physician’s orders should have included the air mattress use.
Respiratory Equipment Not Cleaned or Used as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required respiratory equipment and oxygen therapy. One resident used a BiPAP machine at bedtime for chronic respiratory failure and amyotrophic lateral sclerosis, but the nasal mask was observed with hair and yellowish residue inside it, and the mask had moisture on the nightstand where it had been placed. The resident stated the mask was removed and left on the nightstand without cleaning. The resident’s care plan did not include interventions for cleaning, sanitizing, maintaining, replacing tubing, or storing the BiPAP equipment, and the electronic record did not show documentation that the facility was cleaning the BiPAP. Staff interviews showed inconsistent understanding of who was responsible for cleaning and how often the BiPAP equipment should be cleaned. CNAs stated they were responsible for cleaning the equipment, but one CNA described cleaning it daily while another said it was cleaned weekly. The assistant director of nursing stated there were no orders or tasks for cleaning and sanitizing the BiPAP equipment, although she said there should be a daily cleaning task and that staff were responsible for disinfecting and maintaining it. The director of nursing stated the general process was weekly cleaning unless visibly soiled, and also stated nurses were responsible for applying CPAP and BiPAP equipment and were ultimately responsible for cleaning the nasal pillow. A second resident had active CPAP orders, but the resident stated she no longer used the CPAP because she was on oxygen at all times and believed her physician had told her to stop using it. Despite that statement, the record showed an active CPAP order for bedtime use and an order to fill the chamber with distilled water at bedtime and empty and clean the chamber and mask in the morning. The CPAP nasal cannula was observed with visible dust buildup on the portion inserted into the nose. The resident’s physician orders also failed to specify an oxygen flow rate, even though staff documented oxygen use and stated they typically used 2 liters per minute and adjusted as needed to keep oxygen saturation above 90 percent. Staff interviews reflected uncertainty about whether the resident was refusing CPAP or whether it was simply not being used, and documentation of physician notification regarding CPAP refusals was not present.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure injuries received care consistent with professional standards of practice. The resident, who had recently undergone hip surgery, was admitted without any pressure injuries. Despite the facility's initial implementation of a pressure-reducing mattress, no interventions were put in place to offload the resident's heels, which were at increased risk due to decreased mobility. Within three days of admission, the resident developed blisters on both heels, which later worsened and required surgical debridement at the hospital. The facility's care plan for the resident included the use of a pressure-reducing mattress and a new recliner, but it did not initially include heel booties or an air mattress overlay. These interventions were only implemented after the blisters had already developed. The resident's condition continued to deteriorate despite subsequent treatments and interventions, leading to the resident's discharge to the hospital for further wound treatment. The facility's failure to identify the resident's risk for pressure injuries and to implement timely interventions resulted in the development and worsening of the resident's heel wounds. Interviews with the facility's DON and other staff revealed that the resident was compliant with interventions such as wearing bunny boots and offloading his heels. However, the facility did not implement these measures until after the wounds had developed. The facility also failed to document that the wounds were unavoidable until after the survey exit. The resident's rapid onset of heel blisters was attributed to comorbidities, but the facility's delayed response in implementing appropriate interventions contributed to the severity of the pressure injuries.
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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) |
|---|---|---|---|---|
| Boulder Canyon Health And Rehabilitation | 0.6 mi | ★★★★★ | 6 | 0 |
| Boulder Post Acute | 2.9 mi | ★★★★★ | 15 | 0 |
| Winding Trails Post Acute | 3.7 mi | ★★★★★ | 2 | 0 |
| Coal Creek Post Acute & Assisted Living | 7.6 mi | ★★★★★ | 1 | 0 |
| Adara Living | 10.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.