5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Boulder, CO
2-star overall rating with 2-star inspections with abuse icon flag with $9,113 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2121 Mesa Dr, Boulder, CO
(303) 442-4037
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
162
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.34
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.03
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
4,464
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.07
Baseline 75.54% · Performance 57.43% · Measure score 3.07 · Achievement 1.53 · Improvement 3.07
Adjusted total nurse staffing
4.9
Baseline 4.24 hours · Performance 4.47 hours · Measure score 4.9 · Achievement 4.9 · Improvement 0.99
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.29% |
8.2%
3.9 pts worse
|
Numerator 6 · Denominator 140 |
| Staff flu vaccination coverage | 95.73% |
42%
53.7 pts better
|
Numerator 157 · Denominator 164 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
93.5%
7.1 pts worse
|
93.4%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.4% · Q2 85.4% · Q3 94.4% · Q4 84.7% · 4Q avg 86.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.4%
0.7 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.6% · Q3 5.6% · Q4 4.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
7.4%
4.4 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.5% · Q3 0.9% · Q4 1.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.0%
0.7 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.2% · Q3 6.8% · Q4 2.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
11.2%
13.5 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 25.8% · Q3 26.3% · Q4 23.8% · 4Q avg 24.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.2% |
20.6%
19.6 pts worse
|
16.7%
23.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.6% · Q2 40.0% · Q3 37.7% · Q4 38.5% · 4Q avg 40.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.3% |
15.2%
7.9 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 4.3% · Q3 10.0% · Q4 3.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
14.6%
7.2 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 4.2% · Q3 2.6% · Q4 7.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.8%
0.6 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.5%
0.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 3.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
22.4%
2.6 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 27.2% · Q3 14.5% · Q4 23.4% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
3.7%
3.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.6% |
76.4%
5.8 pts worse
|
81.7%
11.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.7% · Q2 80.4% · Q3 88.2% · Q4 63.2% · 4Q avg 70.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
12.8%
0.2 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 13.6% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 3.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
75.6%
16.1 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
20.3%
1.2 pts worse
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.2% · Expected 20.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-15
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-19
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-29
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-05-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-27
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-15
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-23
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-15
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-09-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-09-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-10-15
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-10-15
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-12
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-06
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-06
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-06
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-15
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-13
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-05
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-05
Health
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 2022-12-05
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-05
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-12-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-05
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-12-05
Health
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 2022-12-05
Health
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 2022-12-05
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-12-05
Health
Provide activities to meet all resident's needs.
Corrected 2022-12-05
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-12-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-09-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-09-15
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-09-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-29
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-17
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-09-10
Penalties and ownership
Fine · fine $9,113
Fine
Contracted Managing Employee · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Boulder, CO
1-star overall rating with 1-star inspections with abuse icon flag with $101,829 in total fines with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Boulder, CO
5-star overall rating with 4-star inspections with 5 recent health deficiencies
Boulder, CO
5-star overall rating with 4-star inspections with $49,202 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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