Cycle 1
Health 2024-04-16 · Fire 2024-04-16
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Boulder, CO
Frasier Meadows Health Care Center
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
4950 Thunderbird Dr, Boulder, CO
(303) 499-8412
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
3.37
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.83
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.47
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,016
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.97
Baseline 19.18% · Performance 19.13% · Measure score 4.97 · Achievement 4.97 · Improvement 0
Healthcare-associated infections
4.98
Baseline 5.80% · Performance 6.35% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Total nurse turnover
8.28
Baseline 14.54% · Performance 29.83% · Measure score 8.28 · Achievement 8.28 · Improvement 0
Adjusted total nurse staffing
6.19
Baseline 4.85 hours · Performance 4.84 hours · Measure score 6.19 · Achievement 6.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.82% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 121 · Observed rate 3.31% · Lower 95% interval 5.75% |
| Discharge to community | 66.13% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 112 · Observed rate 69.64% · Lower 95% interval 57.93% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 79.63% |
95.27%
15.6 pts worse
|
Numerator 43 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 72.34% |
53.69%
18.7 pts better
|
Numerator 34 · Denominator 47 |
| Discharge mobility score | 70.21% |
50.94%
19.3 pts better
|
Numerator 33 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 2.86% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 45.63% |
8.2%
37.4 pts better
|
Numerator 47 · Denominator 103 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 115 · Denominator 115 |
| Discharge function score | 72.34% |
56.45%
15.9 pts better
|
Numerator 34 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 4.35% |
25.2%
20.9 pts worse
|
Numerator 1 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.2 |
1.3
1.1 pts better
|
1.9
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.1 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.7
1.7 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
93.5%
6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 2.1% · Q4 2.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
7.4%
6.9 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.0%
1.2 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.6% · Q4 7.1% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.7% |
11.2%
5.5 pts better
|
19.6%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.6% · Q3 3.6% · Q4 7.1% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
20.6%
7.8 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 13.0% · Q3 13.0% · Q4 13.6% · 4Q avg 12.8% · 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 | 6.3% |
15.2%
8.9 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.0% |
14.6%
12.6 pts better
|
14.9%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.7% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
22.4%
3 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 26.7% · Q3 14.1% · Q4 4.2% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
76.4%
21 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 97.6% · Q3 100.0% · Q4 97.0% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
12.8%
3.4 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 7.4% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
75.6%
16.9 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.0% |
20.3%
4.3 pts better
|
23.9%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 11.1% · Expected 16.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-10 · Fire 2023-01-10
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-09-16 · Fire 2021-09-16
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-31
F · Potential for more than minimal harm
2024-04-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-04-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-16
K222 · Egress Deficiencies
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 2024-06-30
E · Potential for more than minimal harm
2024-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-04-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-11
D · Potential for more than minimal harm
2024-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-15
F · Potential for more than minimal harm
2023-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-31
F · Potential for more than minimal harm
2023-01-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-01-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-01-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-14
D · Potential for more than minimal harm
2021-09-16
K222 · Egress Deficiencies
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 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-09-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-01-17
Inspection history
Recent health citations
G · Actual harm
2024-04-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-09
G · Actual harm
2023-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-15
E · Potential for more than minimal harm
2023-01-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-01-15
D · Potential for more than minimal harm
2021-09-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-09-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-09-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-10-05
D · Potential for more than minimal harm
2021-09-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-16
Penalties and ownership
What sits behind the stars
$21,678
2024-04-16
Fine
Fine · fine $21,678
Fine
$13,762
2023-10-30
Fine
Fine · fine $13,762
Fine
$13,762
2023-09-11
Fine
Fine · fine $13,762
Fine
Ownership
Lewis, Nikki
5% Or Greater Direct Ownership Interest · Individual
Lewis, Nikki
Corporate Officer · Individual
Mcparland, Michelle
Operational/Managerial Control · Individual
Mcparland, Michelle
Corporate Director · Individual
Nearby options
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#2
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#3
Winding Trails Post Acute
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