Boulder Post Acute

Inspectors wroteBased on observations and interviews the facility failed to ensure food was distributed and served under sanitary conditions in the main kitchen. Specifically, the facility to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination in the main kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of six medication carts. Specifically, the facility failed to ensure inhaler medications and multi-use vials of injectable medications were marked with the date when the medications were opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #8) of five residents out of 43 sample residents. Specifically, the facility failed to:-Obtain orders for Resident #1's midline catheter (tube inserted into a vein to administer medication) dressing change;-Change Resident #1's midline catheter dressing in a timely manner; and,-Follow physician's orders for Resident #8's sliding scale insulin.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#1) of one resident reviewed with a feeding tube out of 43 sample residents. Specifically, the facility failed to ensure Resident #1 received her tube feedings per physician's orders.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure three (#53, #62 and #84) of three residents of 43 sample residents received food prepared in the form designed to meet their individual needs. Specifically, the facility failed to ensure Resident #53, Resident #62 and Resident #84, who were prescribed mechanically altered diets, had food prepared according to their diet orders.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene while assisting residents with eating; and,-Don (put on) appropriate personal protective equipment (PPE) when entering Resident #1's room, who was on transmission-based precautions; and,-Ensure housekeeping staff followed appropriate infection control guidelines when cleaning residents' rooms.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of five residents was kept free from abuse out of five sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from sexual abuse by Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one (#1) of five residents out five sample residents. Specifically, the facility failed to develop and implement effective dementia management focused interventions to prevent Resident #1 from wandering into other resident's rooms.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#2 and #3) of five residents out of nine sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #2 was kept free from abuse by Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to report two incident of potential sexual abuse involving Resident #2 and Resident #8 to the State Agency.

Inspectors wroteBased on record review, the facility failed to investigate incidents of abuse involving two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to conduct investigations of two incidents of potential sexual abuse involving Resident #2 and Resident #8.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#3) of three residents received treatment and care in accordance with professional standards of practice out of 15 sample residents. Specifically, the facility failed to: -Investigate, treat, and implement interventions to prevent wounds to the resident's knees; and, -Complete routine weekly skin assessments.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for four (#100, #92, #97 and #70) of six residents out of 42 sample residents. Specifically, the facility failed to provide meaningful activities, including activities of personal choice, for Resident #100, Resident #92, Resident #97 and Resident #70.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in three of five nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated in the nourishment rooms; and, -Ensure personal food items belonging to staff were not kept in facility nourishment refrigerators.

Inspectors wroteBased on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#63) of three residents reviewed for PASRR out of 42 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #63.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#48) of four residents reviewed for quality of care out of 44 sample residents. Specifically, the facility failed to honor the resident's choice to be sent to the hospital upon her request. On 9/26/22 Resident #48 developed altered mental status and functional decline in mobility. The resident had difficulty communicating her thoughts, but expressed to multiple staff members that she needed to go to the hospital. Her request was not honored. Her condition continued to deteriorate, and she was hospitalized on [DATE] after the state of her health condition was brought to the attention of a nurse practitioner (NP) #2 by the resident's speech therapist (ST). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain a comfortable environment for residents on three of five units. Specifically, the facility failed to ensure comfortable room temperature levels for Unit #1, Unit #2 and Unit #4.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure three (#99, #11 and #77) of seven residents reviewed for activities of daily living of 44 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to: -Ensure that Resident #99 and Resident #11 received regular showers; and, -Ensure that Resident #99 and Resident #77 received nail care.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and meet the nutritional needs of the residents. Specifically, the facility failed to: -Ensure the resident food was palatable in taste, texture and appearance; and, -Ensure the resident food met the nutritional needs of the residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and five out of five satellite kitchens. Specifically, the facility failed to: -Ensure food was labeled and dated in the walk-in refrigerators in the main kitchen and dry storage; -Ensure the main kitchen was clean and sanitary; -Ensure five unit refrigerators were clean and sanitary; -Ensure garbage was covered and disposed of in the main kitchen; -Ensure food was properly cooled; and, -Ensure holes were fixed timely in the main kitchen.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on four of five units. Specifically, the facility failed to: -Ensure food that was kept in resident's refrigerators had safe and sanitary storage; -Ensure resident refrigerators had a thermometer to continuously monitor the internal temperature; and, -Ensure documentation monitored daily refrigerator temperatures.

Inspectors wroteBased on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of five units. Specifically, the facility failed to: -Provide and encourage hand hygiene to residents at meal times; and, -Staff did not follow proper hand hygiene during meal assistane.

Inspectors wroteBased on observations and interviews, the facility failed to follow proper testing procedures and infection control measures to prevent potential cross-contamination and spread of SARS-CoV-2 COVID-19, during testing procedures on staff and residents. Specifically, the facility failed to ensure proper disinfection of the testing area (a facility bathroom) between staff self-tests; and that the entire testing area and all items in the testing area (within six feet of the testing) were properly disinfected every hour during the testing period.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#99 and #11) of five out of 44 sample residents had the right to formulate an advanced directive. Specifically, the facility failed to ensure Resident #99 and Resident #11's advanced directives matched the physician's orders.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#89) out of five residents reviewed for grievances out of 44 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #89's grievances, for which was communicated to staff on multiple occasions.

Inspectors wroteBased on record review and interviews, the facility failed to have a completed discharge summary that included a recapitulation of the stay for one (#144) of three residents reviewed for discharge out of 44 sample residents. Specifically, the facility failed to ensure the facility accepting Resident #144 for admission received a discharge summary to include all required components; including: -An accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care was coordinated and the resident transitioned safely from one setting to another; -Detailed and accurate information to reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental, and psychosocial well-being were provided for one (#89) out of six reviewed for activities of 44 sample residents. Specifically, the facility failed to ensure activities that met Resident #89's interests were offered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of outside providers and staff. The facility was unable to provide an accurate listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. The facility failed to prevent unvaccinated staff from working, without an exemption or temporary delay: -Certified nursing aide (CNA) #5 worked from 5/26/22 to 11/9/22 without having primary vaccinations or exemption; and, -Dietary aide (DA) #1 worked from 7/18/22 to 8/27/22 without having primary vaccinations or exemption. [...]