Boulder Park Terrace

In the surveyor’s words

From the most serious findings on record at Boulder Park Terrace, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of existing pressure injuries and prevent the development of two additional pressure injuries for one Resident (#60) of two residents reviewed for wounds. This deficient practice resulted in harm when R60 developed two stage II pressure injuries to bilateral heels.Findings include:Resident #60 (R60)Review of R60's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/8/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (a stroke causing partial or complete paralysis on the right side of the body), chronic kidney disease, diabetes mellitus, and bilateral cataracts… […]

• Actual harm, isolatedF692Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent significant weight loss in one Resident (#28) of two residents reviewed for nutrition. This deficient practice resulted in a weight loss of 45.8 pounds (21.8%) over a six-month period.Findings include:Resident #60 (R60)Review of R60's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/8/26 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (a stroke causing partial or complete paralysis on the right side of the body), chronic kidney disease, diabetes mellitus, and bilateral cataracts (cloudy areas that form on the lens of the eye resulting in vision impairments). […]

• Actual harm, isolatedF600Nov 21, 2025

  Based 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. Findings include: This citation pertains to intake: 2667693Resident #6 (R6)Review of the Electronic Medical Record (EMR) for R6 revealed admission to the facility on 9/1/25 with diagnosis of cerebral infarction. R6 scored an 8/15 on a Brief Interview for Mental Status (BIMS) score dated 9/5/25, indicating moderate cognitive impairment. However, the medical record indicated R6 was responsible for their own medical and financial decisions.An interview was conducted with Social Services Director (SSD) M on 11/20/25 at 1:30 p.m. […]

• Actual harm, isolatedF602Nov 21, 2025

  Based 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. Findings include: This citation pertains to intake: 2615537Resident #5 (R5)Review of R5's Electronic Medical Record (EMR) revealed admission to the facility on 7/2/25 and discharge on [DATE]. Review of R5's medical diagnosis included metabolic encephalopathy (brain dysfunction caused by chemical imbalance).On 8/30/25, Family Member N was visiting R5 who was actively dying at the facility and stayed until approximately 3:30 a.m. Family Member N noted during the visit, R5 had her gold wedding band and solitaire diamond band on her fingers. […]

• Actual harm, isolatedF686Nov 21, 2025

  Findings 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. […]