Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B+
Grade
59
Score
CMS Ratings
11.4/22
Staffing Quality
11.6/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate58.0%
150
Total Beds
87
Occupied
63
Available

Basic Information

Address:

2800 PALO PKWY

BOULDER, CO 80301

Number of Beds:

150

Estimated Occupancy:

58% (~63 available)

Chain:

PACS GROUP

Quality Ratings

Overall Rating:2/5 Stars
Health Inspection:1/5 Stars
Staffing Rating:4/5 Stars
Quality Measures:5/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

065267

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Average

This Facility

0.61

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Below Average

This Facility

3.20

hours

National Avg

3.89

hours

Breakdown:

RN: 0.61hLPN: 0.82hAide: 1.77h

Staff Turnover Rate

Annual nursing staff turnover

Below Average

This Facility

31.0%

National Avg

46.6%

RN Turnover: 27.3%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 10 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

138

Inspections

8

Critical

10

High

16

Nov 21, 2024 - Health Survey

16 deficiencies cited

Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Dec 20, 2024
Medium - PatternTag F0570

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

Corrected: Dec 12, 2024
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 13, 2024
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Dec 20, 2024
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Dec 20, 2024
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Dec 20, 2024From Complaint
Medium - PatternTag F0565

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected: Dec 20, 2024From Complaint
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Dec 20, 2024
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Dec 20, 2024
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Dec 20, 2024
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 13, 2024
Medium - PatternTag F0570

Resident Rights Deficiencies

Assure the security of all personal funds of residents deposited with the facility.

Corrected: Dec 12, 2024
Medium - PatternTag F0554

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected: Dec 20, 2024
Medium - PatternTag F0565

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected: Dec 20, 2024From Complaint
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Dec 20, 2024From Complaint
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Dec 20, 2024

Oct 15, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Nov 1, 2024From Complaint
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Nov 1, 2024From Complaint

Mar 7, 2024 - Health Survey

28 deficiencies cited

Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Jun 21, 2024From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jun 29, 2024From Complaint
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 17, 2024From Complaint
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 17, 2024From Complaint
High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: May 9, 2024From Complaint
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0940

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Jun 21, 2024From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jun 29, 2024From Complaint
Medium - PatternTag F0607

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 17, 2024From Complaint
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 17, 2024From Complaint
High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: May 9, 2024From Complaint
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0940

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected: Apr 17, 2024From Complaint
Medium - PatternTag F0947

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected: Apr 17, 2024From Complaint

Nov 20, 2023 - Health Survey

8 deficiencies cited

Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Dec 18, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Dec 18, 2023From Complaint

Jun 15, 2023 - Health Survey

28 deficiencies cited

Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: Aug 8, 2023
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jul 18, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 18, 2023
Medium - PatternTag F0923

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected: Jul 18, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 18, 2023
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 18, 2023
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jul 18, 2023
Medium - PatternTag F0574

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Corrected: Jul 18, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 18, 2023
Medium - PatternTag F0574

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

Corrected: Jul 18, 2023
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 18, 2023
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 18, 2023
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 18, 2023
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 18, 2023
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 18, 2023
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Jul 18, 2023
Medium - PatternTag F0813

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected: Jul 18, 2023
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 18, 2023
Medium - PatternTag F0923

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected: Jul 18, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 18, 2023
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jul 18, 2023
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Aug 18, 2023
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 18, 2023
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Jul 18, 2023
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Jul 18, 2023
Medium - PatternTag F0813

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected: Jul 18, 2023
Medium - PatternTag F0849

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected: Aug 8, 2023
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jul 18, 2023

Mar 23, 2023 - Health Survey

2 deficiencies cited

High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 26, 2023From Complaint
High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Apr 26, 2023From Complaint

Jul 28, 2022 - Health Survey

2 deficiencies cited

Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 4, 2022
Medium - PatternTag F0584

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected: Sep 4, 2022

Apr 19, 2022 - Health Survey

52 deficiencies cited

High - Widespread PatternTag F0603

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected: Jun 14, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Jun 14, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jun 14, 2022
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Jun 14, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jun 14, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jun 14, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jun 14, 2022
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jun 14, 2022
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jun 14, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0603

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected: Jun 14, 2022
Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Jun 14, 2022
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Jun 14, 2022
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jun 14, 2022
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Jun 14, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jun 14, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jun 14, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jun 14, 2022
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jun 14, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jun 14, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 14, 2022
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Jun 14, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Jun 14, 2022
Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Jun 14, 2022
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0837

Administration Deficiencies

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected: Jun 14, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0841

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: May 18, 2022
Critical - Actual HarmTag F0886

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0888

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Corrected: Jun 14, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jun 14, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 14, 2022
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Jun 14, 2022
Medium - PatternTag F0758

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected: Jun 14, 2022
Medium - PatternTag F0761

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected: Jun 14, 2022
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0837

Administration Deficiencies

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected: Jun 14, 2022
Medium - PatternTag F0838

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0841

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected: Jun 14, 2022
High - Widespread PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: May 18, 2022
Critical - Actual HarmTag F0886

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Corrected: Jun 14, 2022
Critical - Actual HarmTag F0888

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Corrected: Jun 14, 2022
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jun 14, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Jun 14, 2022
Medium - PatternTag F0585

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected: Jun 14, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

2 penalties in the past 3 years

Total fines: $90,659

FineMarch 7, 2024

$90,659

Data processed: August 1, 2026

Payment DenialMarch 7, 2024

Payment Denial: Started April 5, 2024

Duration: 85 days

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

Low Staff Turnover
31.0% (national avg: 46.6%)
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Beds Available
Approximately 63 beds potentially available
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Part of Healthcare Chain
PACS GROUP

Frequently Asked Questions

What is the quality rating for WINDING TRAILS POST ACUTE?

WINDING TRAILS POST ACUTE has an overall CMS rating of 2 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

WINDING TRAILS POST ACUTE has 150 certified beds. The facility averages 87 residents per day, with an occupancy rate of approximately 58%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the PACS GROUP network.

How can I contact WINDING TRAILS POST ACUTE?

You can call WINDING TRAILS POST ACUTE at (303)440-9100. The facility is located at 2800 PALO PKWY, BOULDER, CO 80301.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: