Boulder Post Acute

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Egress Deficiencies

Install proper backup exit lighting.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Egress Deficiencies

Install proper backup exit lighting.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

A survey for Incident #39936, Incident #39989 and complaint #CO40040 was completed on 5/7/25 to 5/13/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure an environment free of accident hazards for one (#1) of one resident reviewed for accidents/hazards out of 10 sample residents.Resident #1, who was at risk for elopement, required 15-minute safety checks due to inappropriate behaviors with staff and residents unrelated to his elopement risk. The staff on the fourth floor where Resident #1 resided were to observe Resident #1 and document his behaviors with the 15-minute safety checks.-However, the two certified nurse aides (CNA) and one licensed practical nurse (LPN) on duty the night of 4/11/25 failed to perform Resident #1' s 15-minute safety checks per facility protocol (see nursing home administrator' s (NHA) interview below). On 4/11/25 at approximately 8:14 p.m. Resident #1 rode an elevator in the facility from the fourth floor down to the first floor, walked to the front door, opened the front door, which set off an alarm, and left the facility. A staff member heard the alarm and looked out a window, however, the staff member failed to go outside and search for anyone. When the staff member did not see anyone outside, the door was relocked and the alarm was reset. At approximately 4:00 a.m. on 4/12/25 (almost eight hours after the resident left the facility through the front door, setting off the alarm) a CNA noticed Resident #1 was.. Based on record review and interviews, the facility failed to ensure two (#2 and #3) of four residents were free from abuse out of 10 sample residents.Specifically, the facility failed to ensure Resident #2 and Resident #3 were free from physical abuse by each other. On 4/16/25 Resident #2 attempted to strike Resident #3. Resident #3 responded by grabbing Resident #2. Both residents fell to the ground. Resident #3 sustained a left humerus (shoulder) fracture. Resident #2 sustained bruising to his arm and an abrasion to his back. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, 2024, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:15 a.m. via email. It read in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or ..

A survey prompted by complaint #CO40139 was completed on 5/7/25 to 5/13/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure two (#2 and #3) of four residents were free from abuse out of 10 sample residents.Specifically, the facility failed to ensure Resident #2 and Resident #3 were free from physical abuse by each other. On 4/16/25 Resident #2 attempted to strike Resident #3. Resident #3 responded by grabbing Resident #2. Both residents fell to the ground. Resident #3 sustained a left humerus (shoulder) fracture. Resident #2 sustained bruising to his arm and an abrasion to his back. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, 2024, was provided by the nursing home administrator (NHA) on 5/7/25 at 10:15 a.m. via email. It read in pertinent part,"It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. "Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. "Serious bodily injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalizatio..