Boulder Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 13, 2025

  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). […]

• Actual harm, isolatedF600May 13, 2025

  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 procedure The 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. […]

• Actual harm, isolatedF684Dec 1, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 19, 2026

  Based 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. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary manner. A. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24) and retrieved on 2/23/26 read in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissues, spatulas, tongs, single-use gloves or dispensing equipment. […]

• No harm, potential for more than minimal, patternF761Feb 19, 2026

  Based 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.Findings include:I. Professional referenceAccording to the haloperidol deconate injection package insert, retrieved on [DATE] from https//fresenius-kabi.com/content/dam/fresenius-kabi/ca/products/product-documents/iv-drugs/haloperidol-injection-usp_/Product%20Monograph.pdf.coredownload.inline.pdf, Multiple-dose vials: Discard unused portion 28 days after initial puncture.According to the Spiriva… […]