Boulder Park Terrace

Inspectors wroteBased on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a resident transfer or discharge for three Residents (#51, #55, & #58) of three residents reviewed for discharge processes.

Inspectors wroteThis deficient practice pertains to Intake 2805315. Based on observation, interview and record review, the facility failed to provide sufficient staffing to address the care, needs, and safety of the entire facility population. Review of a complaint submitted to the State Agency (SA) on 3/17/26 read, in part: .There are 2 nurses in the building, and there should be a minimum of 3. The DON [Director of Nursing], Infection Control Nurse, and Administrator are all out of the building. We are drowning here with no staff. Send help!On 3/24/26 at 1:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) L regarding staffing levels in the facility. CNA L stated the facility is constantly understaffed, often running with just two CNAs for a census of 50 or more. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a comprehensive facility assessment which included specific staffing needs by shift and census, a plan to maximize recruitment and retention of direct care staff, and a contingency staffing plan.

Inspectors wroteThis deficient practice pertains to Intake 2805315. Based on observation, interview, and record review the facility failed to ensure a sufficient supply of:Incontinence products for Residents #6, #9, #10, and #11. Urinary catheter components for Residents #2 and #15. Custodial products for routine trash removal.

Inspectors wroteThis deficient practice pertains to Intake 2805315. Based on observation, interview, and record review the facility failed to ensure the appropriate colostomy supplies were provided for one Resident (#5) of one Resident reviewed for colostomy care. This deficient practice resulted in feelings of extreme embarrassment and social withdrawal due to noxious odors from fecal leakage.

Inspectors wroteBased on interview and record review, the facility failed to protect the right to be free from verbal abuse by staff for one Resident (#6) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free of misappropriation of property by staff. This deficient practice resulted in psychosocial harm based on the reasonable person perspective.

Inspectors wroteFindings include: Resident #7 (R7)Review of R7's face sheet revealed an admission to the facility on 7/30/24, with diagnoses including constipation, heart failure, diabetes mellitus, and hypertension (elevated blood pressure). Review of R7's quarterly Minimum Data Set (MDS) assessment, dated 10/17/25, revealed R7 required substantial maximal assistance from staff for activities of daily living cares including toileting, shower/bathing, upper/lower body dressing, and putting on/taking off footwear. R7's brief interview for mental status (BIMS) revealed moderate cognitive impairment. Section M Skin revealed R7 had a facility acquired stage II pressure ulcer (an open sore on the skin that involves partial-thickness loss of dermis) that was unhealed, and indicated R7 was at risk for developing additional pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate pain control was achieved for one Resident (Resident #7) of three residents reviewed for pain management. This deficient practice resulted in Resident #7 experiencing excruciating uncontrolled pain during pressure ulcer dressing changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician-prescribed bowel protocol was followed for two Residents (#3 & #7) of three residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide family notification with injury that had the potential for requiring physician intervention for one Resident (R1) of three residents reviewed for notification of change. This deficient practice resulted in the delay in notification per the resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to form a recapitulation of stay for one Resident (R2) of three residents reviewed for discharge.

Inspectors wroteBased on interview and record review the facility failed to follow care plan interventions to prevent a fall for one Resident (R1) of three residents reviewed for falls.

Inspectors wroteThis citation pertains to intake 121993. Based on interview and record review, the facility failed to accurately transcribe and implement physician orders for pressure ulcer treatment of one Resident (#7) of three residents reviewed for wound care. This deficient practice had the potential for worsening and/or delayed wound healing condition. Resident #7 (R7)Review of the electronic medical record revealed R7 was originally admitted to the facility from the hospital on 6/12/25 with active diagnosis of pressure ulcer sacral region, unspecified stage, altered mental status, and osteoarthritis. The hospital discharge summary indicated apply Medihoney (Active Leptospermum honey, promotes healing) and cover with Mepilex (silicone foam dressing) daily to the sacral pressure ulcer. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify areas of improvement through its Quality Assurance and Performance Improvement (QAPI) program of five concerns, Advanced Beneficiary Notification (ABN), care plan updates, medication consents, proper reporting of abuse, and Preadmission Screening and Annual Resident Review (PASARR) identified by the survey team. The deficient practice has the potential for negative resident outcomes, and placed residents at risk for harm due to lack or proactive system-level interventions.

Inspectors wroteThe facility presented a list of residents whose Medicare Part A Service had ended and were eligible to receive a SNF ABN (a document to alert of payment changes). Three Residents (R37, R41 and R56) on this list were chosen and their medical records were requested to assure proper notification had been delivered. The medical record form: SNF Beneficiary Notification Review was received for R37, R41 and R56 and each read, Was a SNF ABN, From CMS-10055 (Center for Medicare and Medicaid Services) provided to the resident? Each form had No checked and continued, If no, explain why the form was not provided. Each had a handwritten explanation which read, Change in BO (Business Office) Staff. During an interview on 6/5/25 at 12:50 PM, the Nursing Home Administrator (NHA) stated there had been a recent change in office personnel within the last month. [...]

Inspectors wroteResident #258 (R258) Review of an admission Record revealed R258 was originally admitted to the facility on [DATE]. On 6/4/25 at 9:33 AM., R258 was observed on a stretcher being wheeled out via ambulance/paramedics. On 6/4/25 at 9:35 AM, Certified Nurse Aide (CNA) C was interviewed and reported R258 was not feeling well this morning, and reported this to the nurse, and a decision was made to send R258 out to the Emergency Department (ED). Review of R258's Electronic Medical Record EMR revealed. 6/04/2025 05:32 PM Late Entry- Resident observed to be confused/difficult to arouse/complaining of feeling cold. Weak. Altered mental status Call placed to EMS (Emergency Medical Services) to transport to Hospital for evaluation NP notified/ DON (Director of Nursing) notified . Resident sent out at approx 0930. - Resident is being admitted . [...]

Inspectors wroteResident #263 (R263) Review of an admission Record revealed R263 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Enterococcus bacteremia (blood stream infection). Review of a Minimum Data Set (MDS) assessment for R263 with a reference date of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R263 was cognitively intact. In an interview on 6/4/25 at 2:08 PM., R263 reported staffing is so short he has to wait for assistant for long periods of time. R263 reported there are just not enough of them to help out the way they should be. R263 reported his call light took over 45 minutes the other night. In an interview on 6/4/25 at 9:35 AM., Certified Nurse Aide (CNA) C reported (staffing could be better, we struggle making sure everyone gets their showers on time or on their scheduled days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to facility failed to ensure drugs and biological's were stored and discarded according to professional standards and ensure a locked medication room had a functional door handle/lock for 1 of 2 medication storage rooms, and 1 of 3 medication carts reviewed for storage of medications resulting in the potential for negative side effects from outdated or ineffective drug therapy and accidental wrong medication ingestion and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent prior to the administration of psychotropic medications for two Residents (#16 and #36) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by serving residents their meals on institutional trays in the resident dining rooms.

Inspectors wroteThis citation pertains to intake M00153232 Based on interview and record review, the facility failed to monitor and prevent resident to resident sexual abuse for two Residents (#14 and #40) of four residents reviewed for abuse. This deficient practice resulted in feelings of being violated, humiliation, anxiety.

Inspectors wroteBased on interview and record review, the facility failed to document specific behaviors, signs and symptoms of anxiety targeted by the administration of a PRN (as needed) antianxiety medication for one Resident (#36) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure allegations of abuse were identified and reported to the State Agency (SA) for three Residents (#40, #49 and #22) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated for three Residents (#40, #49 and #22) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that required assessments were completed timely for four Residents (#4, #14, #42 and #44) out of 16 Residents reviewed for MDS (Minimum Data Set) assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II PASARR (Preadmission Screening and Record Review) evaluation was completed on 1 of 1 sampled resident (Resident #41) with known serious mental illness.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate baseline care planning regarding high risks focus areas for two Residents (#256 & #263) of 13 residents reviewed for baseline care planning. This deficient practice resulted in the potential for choking, complications from infections as well as overall unmet medical needs.

Inspectors wroteResident #263 (R263) Review of an admission Record revealed R263 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Enterococcus bacteremia (blood stream infection). Review of a Minimum Data Set (MDS) assessment for R263 with a reference date of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R263 was cognitively intact. Review of R263's medical record revealed no Comprehensive Care Plan was completed. Review of R263's physicians orders revealed: penicillin G pot (potassium) in dextrose (antibiotics) piggyback; 3 million unit/50 mL (milliliters); intravenous (via PICC [peripherally inserted central catheter] line) Other Test: Once A Day IV (intravenous) PCN (penicillin) G 24 million Units every 24 hours continuous infusion. [Diagnosis: Bacteremia] .(start date) 05/07/2025 (end date) 06/09/2025 . [...]

Inspectors wroteThis citation pertains to intake MI00153232 Based on interview and record review, the facility failed to ensure care plans were revised to address supervision behaviors and prevent further abuse regarding two Residents (#14 and #40) of 13 residents reviewed for revision of care plans. This deficient practice resulted in care plans which did not reflect resident needs and had the potential for continued behaviors, including resident to resident abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health care needs to maintain the highest practicable level of physical, mental, and psychosocial well-being, for one Resident (#40) of one resident reviewed for behavioral care. This deficient practice had the potential for worsening behaviors. Resident #40 (R40) Review of the Minimum Data Set (MDS) assessment, dated 5/15/25, revealed R40 was admitted to the facility on [DATE]. R40 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Further review of the Electronic Medical Record (EMR) revealed R40 had a diagnosis of dementia. Section E Behavioral Symptoms: revealed R40 experiences physical behavioral symptoms directed toward others i.e. Hitting, kicking, pushing, scratching, grabbing, abusing others sexually every 4 to 6 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent follow-up and documentation of monthly medication regimen reviews (MRRs) for two Residents (#16 and #36) of five resident reviewed for MRRs.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently document pain assessments and document/utilize non-pharmacological interventions prior to the administration of PRN (as needed) opioid pain medication for one Resident (#49) of five residents reviewed for unnecessary medications, resulting in the potential for adverse medication effects and/or physical dependence on controlled medications.

Inspectors wroteThis deficient practice pertains to Intake MI00148356. Based on observation, interview, and record review, the facility failed to provide food to accommodate resident preferences for one Resident (#3) of 4 residents reviewed for food allergies and preferences. This deficient practice resulted in food dissatisfaction, decreased food consumption, and the potential for further weight loss.

Inspectors wroteThis deficiency pertains to intake numbers MI00145488 and MI00145642 Based on interview and record review, the facility failed to ensure sufficient numbers of staff to provide adequate care to the resident population in accordance with the facility assessment. This deficient practice resulted in the potential for unmet care needs for all 61 residents in the facility.

Inspectors wroteThis citation pertains to intake MI00145682. Based on interview, and record review, the facility failed to provide prompt written responses to concerns/grievances for two residents (R36 and R37) of three residents reviewed for the grievance process. This deficient practice resulted in residents becoming frustrated over feelings of being unheard due to voicing concerns multiple times and perceived lack of facility response.

Inspectors wroteThis deficiency pertains to intake number MI00147266 Based on interview and record review, the facility failed to timely notify the state agency of a resident-to-resident altercation and failed to report the results of an investigation timely to the state agency for three Residents (R34, R35, and R36) of four residents reviewed for abuse.

Inspectors wroteThis deficiency pertains to intake number MI00147266 Based on interview and record review, the facility failed to thoroughly investigate resident-to-resident altercations for three residents (R34, R35, and R36) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the required staffing information on the daily posting for direct care nursing personnel.

Inspectors wroteIntake: MI00144784 Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R601) of three residents reviewed for falls. This deficient practice resulted in actual harm with R601 sustaining a fall with a right hip fracture requiring surgical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 55 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to review resident rights with eight confidential group Residents of eight residents reviewed for awareness of their rights. This deficient practice resulted in feelings of frustration due to the lack of awareness of basic rights.

Inspectors wroteThis citation relates to Intake #MI00142921. Based on observation, interview, and record review, the facility failed to provide appropriate staffing of Certified Nursing Assistants (CNAs) to provide necessary care and services for three Residents (R18, R23, and R48) of 14 sampled residents, and six confidential interviewable Residents from the group meeting facility task. This deficient practice resulted in feelings of frustration related to delay in staff responding to call lights and the potential for adverse resident outcomes.

Inspectors wroteThis citation pertains to intake MI00142921. Based on observation, interview and record review, the facility failed to ensure dignified care experiences for three Residents (R36, R20 and R39) of four residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly assess mental and physical capability for self-administration of medications for one resident (R42) of one resident reviewed for self-administration of medications. Resident #42 (R42) R42's electronic medical record (EMR) revealed an admission date of 6/22/23. R11's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated R42 was cognitively intact. R42 had medical diagnoses including muscular dystrophies (muscle dysfunction), congenital stenosis and stricture of esophagus (abnormal narrowing of esophagus), dysphagia (difficulty swallowing), and acute bronchitis. R42's orders indicated ipratropium-albuterol solution for nebulization; 0.5 milligram (mg)-3 mg (2.5 mg base)/3 mL(milliliters); [...]

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R9 and R23) of 14 residents reviewed for care planning. This deficient practice resulted in the potential to result in unmet activity needs for R9 and additional weight loss for R23.

Inspectors wroteBased on interview, and record review, the facility failed to ensure care plans were updated and revised appropriately for two Residents (R5 and R39) out of 14 Resident care plans reviewed. This deficient practice resulted in care plans which did not reflect resident needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care to prevent worsening of a catheter-associated pressure injury for one Resident (R39) of three residents review for pressure injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations and failed to follow the physician orders after they were written for one Resident (R5) of five residents reviewed for MRR out of a sample of 14 residents. This deficient practice had the potential to result in excessive dosage, side effects, and adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up on routine dental services for one Resident (R5) of one resident reviewed for dental services. This deficient practice resulted in R5's diet being downgraded from a regular diet to a pureed diet with a potential for weight loss and dissatisfaction with meals while waiting for her dentures to be fixed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate care of an indwelling, urinary catheter for one Resident (R39) of one resident reviewed for catheter care.

Inspectors wroteThis citation refers to intake(s): MI00139977 Based on interview and record review, the facility failed to implement appropriate interventions to prevent a fall for one Resident (R2) of three residents reviewed for falls. This deficient practice resulted in R2 sustaining a fall with subsequent injuries requiring staples.

Inspectors wroteThis citation pertains to intake number: MI00144208 Based on interview and record review, the facility failed to follow the physicians order for PT/INR (prothrombin time/international normalized ration) laboratory testing for one Resident (R4) of three residents reviewed for physician orders. This deficient practice resulted in a delay in treatment in response to R4's blood work which subsequently resulted in R4's hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidence by: A. Failing to ensure that refrigerated potentially hazardous foods were dated and discarded on or before the expiration date. B. Failing to properly clean areas with a potential to contaminate food during preparation. This deficient practice has the potential to result in food borne illness among any or all of the 64 residents in the facility.

Inspectors wroteThis citation pertains to intake MI00137070. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for one Resident [R34] of two residents reviewed for abuse. This deficient practice resulted in the potential for physical and psychosocial harm.

Inspectors wroteThis citation pertains to intake MI00137070. Based on interview and record review, the facility failed to implement their abuse policy to prevent physical abuse for one Resident (#34) of two residents reviewed for abuse. This deficient practice resulted in staff to resident physical abuse and the potential for physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed, physician was notified of changes in condition, and documentation was completed for abnormal findings and medications withheld for one resident (Resident #54) out of 64 residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety by following planned interventions and physician orders, monitoring residents, and completing an initial fall risk assessment for a resident at high risk for falls for one resident (Residents #214) out of five residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in the potential for serious injury, and deterioration in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders to ensure safe swallow measures were in place for one Resident #47 (R47) of two residents reviewed for adaptive equipment needs. This deficient practice resulted in the potential for aspiration (inhaling a substance into the airway instead of swallowing to the stomach), leading to possible lung infection such as pneumonia.