Boulder Post Acute

F-F600 failure to protect Resident #1 from sexual abuse.

A 12/26/24 nursing note documented Resident #1 was lying down in the (other) resident bed. The resident tried to get Resident #1 out of her bed and Resident #1 bit her on her left forearm. Residents were separated. Resident #1 was placed on 15 min checks.

-No person centered dementia interventions were provided to Resident #1.

C. Observations

On 2/3/25 at 10:30 a.m. observations on the first floor unit were conducted. Resident #1 was not in her room.

The resident's room did not have any personal pictures, items or signs to help the resident identify her room.

At 10:35 a.m. Resident #1 was located by certified nurse aide (CNA) #2. Resident was asleep in another resident's room. The room belonged to two gentlemen who were not in the room. Resident #1 was woken up and taken to her room by CNA #2.

III. Staff interviews

Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 10:25 a.m. LPN #1 said she was an agency nurse and did not know much about Resident #1. She said she could look up the care plan in her medical record. She said she did not know what Resident #1 looked like or where she was at the moment. She said

she would ask the CNAs, because they knew residents well.

CNA #2 was interviewed on 2/3/25 at 10:30 a.m. She said Resident #1 was not in the common area and not

in her room. She said the resident probably fell asleep in someone else's room (see observations above).

CNA #2 was interviewed a second time on 2/3/25 at 11:05 a.m. She said Resident #1 liked to walk and she occasionally entered rooms of other residents where she would fall asleep. She said Resident #1 was not aggressive and easily redirectable. She said the staff checked on her every 15 minutes, however she was very quick and could be anywhere at any time. She said she was aware of one altercation that Resident #1 had with other residents that occurred on 1/4/25.

LPN #2 was interviewed on 2/3/25 at 4:30 pm. LPN #2 said she was the unit manager for the unit where Resident #1 currently resided. She said Resident #1 wandered around the unit and occasionally entered other resident's rooms. She said the staff checked on the resident every 15 minutes to ensure that she was not in someone else's room. She said some rooms had a stop sign at the entrance to prevent wandering residents from wandering.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 065052 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065052 B. Wing 02/04/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Boulder Post Acute 2121 Mesa Dr Boulder, CO 80304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 The NHA was interviewed on 2/3/25 at 4:50 p.m. The NHA said Resident #1 was on 15 minute checks by staff. He said he was aware that Resident #1 was found in another resident's room earlier today (2/3/25). He Level of Harm - Minimal harm or said the interdisciplinary team would review the interventions to identify why they were not being effective potential for actual harm and would consider additional one to ensure Resident #1 was sleeping in her personal room.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 065052