Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WINDING TRAILS POST ACUTE

BOULDER, CO · 150 certified beds · Last Life Safety survey November 21, 2024

CMS Certification Number 065267 · first certified November 1989

Ownership

Operated by PACS GROUP · For profit - Limited Liability company

Ownership changed September 1, 2023 (change of ownership)from 2800 PALO PARKWAY OPERATIONS LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CO

24 citations — more than 75% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 9 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: May 2026 to November 2026. This facility’s last Life Safety survey was November 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	24
Median facility in CO	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
April 19, 2022	4
June 15, 2023	11
November 21, 2024	9

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
E-0039	Conduct testing and exercise requirements.	2	2024-11-21
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-11-21
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2024-11-21
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-11-21
K-0324	Provide properly protected cooking facilities.	2	2024-11-21
K-0293	Have properly located and lighted "Exit" signs.	2	2024-11-21
K-0712	Have simulated fire drills held at unexpected times.	2	2024-11-21
K-0222	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.	1	2023-06-15

What the citations cover

Citations by CMS category

Smoke Deficiencies 11
Egress Deficiencies 4
Miscellaneous Deficiencies 3
Emergency Preparedness Deficiencies 3
Other 3

Citations by CMS category
Category	Citations
Smoke Deficiencies	11
Egress Deficiencies	4
Miscellaneous Deficiencies	3
Emergency Preparedness Deficiencies	3
Gas, Vacuum, and Electrical Systems Deficiencies	2
Services Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 21, 2024 — 9 citations

Citations issued on November 21, 2024
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (December 30, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (December 23, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 30, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (December 23, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 27, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (December 27, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (December 30, 2024)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (December 30, 2024)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (December 30, 2024)

June 15, 2023 — 11 citations

Citations issued on June 15, 2023
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 15, 2023)
K-0222	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.	Deficient, Provider has date of correction (August 15, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (August 15, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (August 15, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 15, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 15, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 15, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 15, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (August 15, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (August 15, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 15, 2023)

April 19, 2022 — 4 citations

Citations issued on April 19, 2022
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (June 14, 2022)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (June 14, 2022)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (May 16, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 12, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.