Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Accel At Longmont Health And Rehab, Llc | 10.2 mi | — | 47 | 1 |
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