Inspection Reports for
Boulder Canyon Health and Rehabilitation
4685 Baseline Rd, Boulder, CO 80303, United States, CO, 80303
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Colorado average
Colorado average: 5.2 deficiencies/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on adherence to transmission-based precautions and sanitization of vital signs equipment.
Findings
The facility failed to maintain an effective infection control program by not following transmission-based precautions when entering and exiting droplet precaution rooms and by not properly sanitizing vital signs machines between uses.
Deficiencies (2)
F0880: The facility failed to follow transmission-based precautions when entering and exiting droplet precaution rooms, including improper donning and doffing of PPE and incorrect mask usage.
F0880: The facility failed to ensure vital signs machines were sanitized with the correct sanitizing wipes between each use to prevent infection spread.
Report Facts
Residents Affected: Few residents affected as stated in the report
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to improper PPE use and donning/doffing procedures |
| CNA #1 | Certified Nursing Assistant | Named in findings related to improper PPE use and sanitization of vital signs machine |
| CNA #2 | Certified Nursing Assistant | Named in findings related to improper PPE use |
| Director of Nursing | Director of Nursing | Provided education and interviews regarding PPE use and infection control |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 5, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on adherence to transmission-based precautions and sanitization of vital signs machines between uses.
Findings
The facility failed to maintain an effective infection control program by not following transmission-based precautions when entering and exiting droplet precaution rooms and by not properly sanitizing vital signs machines between resident uses, posing a minimal harm risk to a few residents.
Deficiencies (2)
Failure to follow transmission-based precautions when entering and exiting droplet precaution rooms.
Failure to ensure vital signs machines were sanitized between each use to prevent the spread of infection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding improper donning and doffing of PPE in droplet precaution rooms. |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding failure to properly sanitize vital signs machine and improper PPE use. |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding PPE use in droplet precaution rooms. |
| Director of Nursing | Director of Nursing | Interviewed regarding staff PPE expectations, education provided, and proper sanitization procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 2, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate treatment and care during a resuscitation attempt for Resident #9.
Complaint Details
The complaint investigation found that Resident #9 experienced a life-threatening change of condition on 2/29/24. Staff failed to use available emergency equipment, delayed calling EMS, and did not have a licensed nurse remain with the resident during the code. The complaint was substantiated with minimal harm.
Findings
The facility failed to ensure the emergency crash cart and essential resuscitation equipment were used during the resuscitation attempt of Resident #9. Staff did not place a timely call to EMS, did not use a backboard, and a licensed nurse did not remain with the resident until EMS arrived.
Deficiencies (1)
F 0684: The facility failed to use the emergency crash cart and essential resuscitation equipment during a resuscitation attempt for Resident #9. Staff did not call EMS promptly or remain with the resident until EMS arrival.
Report Facts
Residents in sample: 12
Residents affected: 1
Oxygen flow rate: 15
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Resident #9's nurse during resuscitation; failed to delegate 911 call and remain with resident |
| DOR | Director of Rehabilitation | Performed chest compressions and used AED during resuscitation |
| LPN #1 | Licensed Practical Nurse | Arrived shortly after DOR; observed lack of backboard and assisted during resuscitation |
| DON | Director of Nursing | Provided policy and staff training; interviewed regarding incident and follow-up |
| PCP | Primary Care Provider | Interviewed regarding expected resuscitation procedures for Resident #9 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care during a resuscitation attempt for Resident #9.
Complaint Details
The complaint investigation revealed that Resident #9 experienced a life-threatening change of condition on 2/29/24. The facility staff failed to properly use resuscitation equipment, delayed EMS notification, and did not maintain proper nursing presence during the code. The resident was coding for at least seven minutes prior to EMS arrival without appropriate airway management or use of a backboard.
Findings
The facility failed to ensure the emergency crash cart and essential resuscitation equipment were used during the resuscitation attempt of Resident #9, timely EMS notification was not confirmed, and a licensed nurse did not remain with the resident until EMS arrival. Staff did not use a backboard or bag-mask device during CPR, and documentation of the resuscitation was incomplete.
Deficiencies (3)
Failure to utilize emergency crash cart and essential resuscitation equipment during resuscitation attempt for Resident #9.
Failure to ensure timely call to EMS and proper delegation during emergency.
Failure to have a licensed nurse remain with Resident #9 until EMS arrival.
Report Facts
Residents in sample: 12
Residents affected: 3
Oxygen flow rate: 15
Code duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Resident #9's nurse during resuscitation attempt; failed to delegate 911 call and remain with resident |
| DOR | Director of Rehabilitation | Performed chest compressions and used AED during resuscitation |
| LPN #1 | Licensed Practical Nurse | Arrived shortly after DOR; observed lack of backboard and assisted during resuscitation |
| DON | Director of Nursing | Provided policy, conducted staff inservice, and interviewed regarding resuscitation events |
| CNA #1 | Certified Nurses Aide | Assisted with Resident #9 positioning; observed resuscitation but did not see crash cart or bag-mask device used |
| CPRI | CPR Instructor | Provided expert opinion on expected resuscitation procedures and equipment use |
| PCP | Primary Care Provider | Provided medical opinion on resuscitation expectations and equipment use |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, medication management, infection control, and activities of daily living in a nursing home.
Findings
The facility was found deficient in providing a homelike environment, ensuring residents received bathing and personal hygiene according to their preferences, proper medication storage and labeling, and maintaining infection control practices including PPE use and labeling of personal hygiene items.
Deficiencies (4)
F 0584: The facility failed to provide clean washcloths and hand towels in resident rooms on three units and did not repair holes in bathroom doors and ceilings.
F 0677: The facility failed to ensure five residents received assistance with bathing, shaving, and nail care according to their preferences and care plans.
F 0761: The facility failed to ensure expired or discontinued medications were removed timely from medication carts and properly labeled.
F 0880: The facility failed to maintain infection control by not wearing appropriate PPE during a COVID-19 outbreak, improper feeding tube handling, and unlabeled personal hygiene items in shared rooms.
Report Facts
Residents affected: 5
Residents affected: 16
Staff affected: 8
Days since last shower: 27
Shower opportunities: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Responsible for stocking hand towels and washcloths in linen closets |
| CNA #5 | Certified Nurse Aide | Responsible for providing fingernail care and shower documentation |
| LPN #3 | Licensed Practical Nurse | Responsible for overseeing shower refusals and nail care |
| RN #1 | Registered Nurse | Administered tube feeding to Resident #13 |
| DON | Director of Nursing | Oversaw bathing care, medication storage, and infection control practices |
| IP | Infection Preventionist | Provided infection control guidance and education |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident care, environment, medication management, infection control, and activities of daily living at Boulder Canyon Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide a homelike environment with adequate linens, failure to assist residents with activities of daily living such as bathing and grooming, improper medication storage with expired medications present, and lapses in infection control practices including improper PPE use and unlabeled personal hygiene items.
Deficiencies (4)
Failure to provide clean washcloths and hand towels in resident rooms on multiple units and failure to repair holes in bathroom doors and ceilings.
Failure to ensure residents who required assistance with activities of daily living received proper bathing, shaving, and nail care according to their preferences and care plans.
Failure to ensure expired or discontinued medications were removed timely from medication carts.
Failure to maintain infection control program including improper use of PPE during COVID-19 outbreak, improper handling of jejunostomy tube feeding, and unlabeled personal hygiene items in shared rooms.
Report Facts
Residents reviewed for ADLs: 38
Residents affected for ADL deficiencies: 5
Residents affected for infection control deficiencies: 16
Staff affected for infection control deficiencies: 8
Days between showers for Resident #24: 68
Number of staff signed for hygiene labeling inservice: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Interviewed regarding responsibility for stocking hand towels and washcloths |
| Resident #72 | Interviewed about lack of linens and shower assistance | |
| Resident #24 | Interviewed about bathing preferences and hygiene concerns | |
| Resident #54 | Interviewed about nail care and hygiene | |
| Resident #66 | Interviewed about shower frequency and bathing assistance | |
| Resident #26 | Interviewed about bathing assistance and hygiene | |
| CNA #5 | Certified Nurse Aide | Interviewed about shower documentation and hygiene item labeling |
| LPN #3 | Licensed Practical Nurse | Interviewed about shower assistance and nail care responsibilities |
| RN #1 | Registered Nurse | Observed and interviewed regarding jejunostomy tube feeding practices |
| DON | Director of Nursing | Interviewed about bathing policies, medication storage, infection control, and hygiene labeling |
| IP | Infection Preventionist | Interviewed about infection control practices and outbreak management |
| LPN #1 | Licensed Practical Nurse | Observed medication cart with expired insulin vials |
| LPN #2 | Licensed Practical Nurse | Observed medication cart with discontinued nasal spray |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, treatment, infection control, food safety, and facility environment.
Findings
The facility failed to consistently provide activities of daily living support including bathing, nail care, incontinence care, and repositioning for dependent residents. There were delays in scheduling diagnostic imaging after a fall, inadequate respiratory therapist assessments for a resident with a tracheostomy, improper infection control practices during wound and tracheostomy care, unsanitary food storage conditions, and insufficient dining space for residents on the memory care unit.
Deficiencies (6)
F 0677: The facility failed to provide or offer showers and fingernail care according to schedule for dependent and diabetic residents #29 and #23, and failed to provide timely incontinence care and repositioning for residents #7 and #92.
F 0684: The facility failed to timely schedule a CT scan for Resident #51 after a fall; the scan was completed over a month later revealing a pelvic fracture.
F 0695: The facility failed to ensure Resident #18 with a tracheostomy was routinely assessed by a respiratory therapist; last assessment was over a year old and documentation was lacking.
F 0812: The facility failed to ensure food items in unit refrigerators were dated, labeled, and discarded before expiration; expired and unlabeled food items were observed in refrigerators and freezers.
F 0880: The facility failed to maintain infection control during wound and tracheostomy care for Resident #18; gloves were not changed appropriately and hand hygiene was not performed as required.
F 0920: The facility failed to provide sufficient dining space on the memory care unit, resulting in residents eating meals in hallways due to overcrowding and risk of resident altercations.
Report Facts
Scheduled showers vs received showers: 24
Scheduled showers vs received showers: 39
CT scan delay: 34
Expiration dates on food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing wound and tracheostomy care with improper infection control. |
| CNA #2 | Certified Nursing Assistant | Interviewed about shower and nail care practices. |
| CNA #3 | Certified Nursing Assistant | Interviewed about incontinence care and dining room observations. |
| LPN #1 | Licensed Practical Nurse | Interviewed about shower practices and nail care. |
| DON | Director of Nursing | Interviewed multiple times regarding care deficiencies and facility policies. |
| ADON | Assistant Director of Nursing | Interviewed regarding care deficiencies and facility policies. |
| DM | Dietary Manager | Interviewed about food storage and cleaning responsibilities. |
| RD | Registered Dietitian | Interviewed about food safety and refrigerator cleaning. |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care and assistance for activities of daily living, treatment and care, respiratory care, food safety, infection control, and dining accommodations at Boulder Canyon Health and Rehabilitation.
Findings
The facility failed to consistently provide adequate activities of daily living support including bathing, nail care, incontinence care, and repositioning for dependent residents. There was a delay in scheduling a CT scan for a resident after a fall. Respiratory care assessments by a respiratory therapist were not routinely documented. Food items in refrigerators were found expired, unlabeled, or improperly stored. Infection control practices during wound and tracheostomy care were not properly followed. The memory care unit dining room was overcrowded, causing some residents to eat in hallways.
Deficiencies (6)
Failed to consistently provide activities of daily living support including bathing, nail care, incontinence care, and repositioning for dependent residents.
Failed to timely schedule a CT scan for Resident #51 after a fall, resulting in delayed diagnosis of a pelvic fracture.
Failed to ensure Resident #18 with a tracheostomy was routinely assessed by a respiratory therapist and respiratory care was not consistently documented.
Failed to ensure food items were stored and served under sanitary conditions, including expired and unlabeled food in refrigerators.
Failed to maintain infection control during wound care and tracheostomy care, including improper glove use and hand hygiene.
Failed to provide sufficient dining space for residents on the memory care unit, resulting in residents eating in hallways.
Report Facts
Residents reviewed for ADL care: 41
Dependent residents with ADL care failure: 4
Scheduled showers missed: 20
Scheduled showers missed: 30
CT scan delay: 34
Respiratory therapist last assessment date: Apr 1, 2021
Respiratory assessment provided: Nov 3, 2022
Food expiration dates observed: Aug 1, 2022
Food expiration dates observed: Oct 20, 2021
Food expiration dates observed: Oct 27, 2022
Food expiration dates observed: Sep 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed and interviewed regarding wound and tracheostomy care; admitted to improper hand hygiene and glove use |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding ADL care failures, respiratory care, infection control, and food safety; acknowledged deficiencies and plans for education |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding ADL care, food safety, and infection control; provided in-service training on nail care and refrigerator cleaning |
| CNA #2 | Certified Nursing Assistant | Interviewed about shower and nail care practices |
| CNA #3 | Certified Nursing Assistant | Interviewed about incontinence care and dining room observations |
| LPN #1 | Licensed Practical Nurse | Interviewed about shower practices and nail care |
| Dietary Manager | Dietary Manager (DM) | Interviewed about food storage and refrigerator cleaning responsibilities |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed about food safety and refrigerator cleaning |
Inspection Report
Routine
Census: 97
Deficiencies: 10
Date: Jul 20, 2021
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident care, safety, infection control, staffing, and dementia care.
Findings
The facility had multiple deficiencies including failure to accommodate resident shower preferences, failure to ensure resident privacy, failure to maintain a comfortable environment due to noise disturbances, failure to prevent abuse, inadequate supervision to prevent accidents and elopements, failure to provide appropriate respiratory care, insufficient nursing staff, inadequate dementia care and training, and lapses in infection prevention and control practices.
Deficiencies (10)
F0561: Facility failed to accommodate Resident #69's shower preferences and maintain sufficient nursing staff to meet resident needs.
F0583: Facility failed to ensure Resident #146 had visual privacy while in bed, leaving him exposed to hallway view.
F0584: Facility failed to maintain a safe, clean, comfortable environment by not addressing loud noise disturbances and failing to provide clean washcloths and hand towels to residents.
F0600: Facility failed to prevent resident to resident physical abuse and ensure resident safety after abuse allegation involving agency staff.
F0689: Facility failed to ensure adequate supervision and safety interventions to prevent accidents and elopements for residents #59, #44, and #76.
F0695: Facility failed to ensure nursing staff documented and provided oxygen therapy according to physician orders for Resident #13.
F0725: Facility failed to ensure sufficient nursing staff were consistently scheduled to provide care for residents.
F0744: Facility failed to provide appropriate dementia care and person-centered interventions to Resident #75 to prevent behavioral issues and resident-to-resident altercations.
F0880: Facility failed to maintain infection control practices including proper PPE use in isolation rooms and disinfection of shared sensory items.
F0943: Facility failed to ensure all nurses and CNAs received dementia management training.
Report Facts
Facility census: 97
Residents with dementia: 39
Residents with behavioral healthcare needs: 42
Residents on secured unit: 15
Staff trained on PPE: 56
Residents on wander guard: 1
Residents on oxygen documented off oxygen: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Reported staffing shortages and difficulty assisting with showers |
| RN #1 | Registered Nurse | Reported shower scheduling and resident preferences not documented |
| CNA #7 | Certified Nurse Aide | Reported workload challenges and shower room availability issues |
| CNA #8 | Certified Nurse Aide | Reported flexible shower schedules and documentation challenges |
| DON | Director of Nursing | Provided multiple interviews regarding staffing, care plans, and infection control |
| NHA | Nursing Home Administrator | Provided interviews regarding staffing and facility conditions |
| LEC | Life Engagement Coordinator | Provided interview regarding dementia care and resident behaviors |
| SDC | Staff Development Coordinator | Provided interviews and training documentation related to PPE and dementia training |
| CNA #2 | Certified Nurse Aide | Observed and interviewed regarding PPE use and resident care |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding dementia care and resident behaviors |
Inspection Report
Routine
Census: 97
Deficiencies: 11
Date: Jul 20, 2021
Visit Reason
Routine inspection of Boulder Canyon Health and Rehabilitation to assess compliance with regulatory requirements including resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident shower preferences due to staffing shortages, failure to ensure resident privacy, failure to maintain a safe and homelike environment due to noise disturbances and lack of clean linens, failure to prevent abuse and ensure resident safety, inadequate supervision to prevent elopements and falls, failure to provide appropriate respiratory care, insufficient nursing staff coverage, failure to provide appropriate dementia care, and failure to maintain infection control practices including proper PPE use and disinfection of shared sensory items.
Deficiencies (11)
Failed to accommodate Resident #69's shower preferences due to insufficient staffing.
Failed to ensure Resident #146's visual privacy while in bed.
Failed to maintain comfortable sound levels for residents due to loud yelling and music from Resident #67 disturbing multiple residents.
Failed to provide clean washcloths and hand towels to residents in their rooms consistently.
Failed to prevent resident to resident physical abuse and ensure resident safety after an allegation of abuse by staff.
Failed to ensure adequate supervision and safety interventions to prevent elopement and falls for residents #76, #59, and #44.
Failed to ensure nursing staff documented and provided oxygen therapy according to physician orders for Resident #13.
Failed to ensure sufficient nursing staff were consistently scheduled to meet resident care needs.
Failed to provide appropriate dementia care and person-centered interventions to Resident #75 to manage behaviors and prevent altercations.
Failed to maintain infection control practices including proper PPE use in isolation rooms and disinfection of shared sensory items.
Failed to provide dementia management training to all nursing and CNA staff.
Report Facts
Facility census: 97
Residents with dementia: 39
Residents with behavioral healthcare needs: 42
Residents requiring two person assistance: 9
Residents requiring one person assistance: 55
Residents bedfast: 8
Staff educated on PPE use: 56
Opportunities oxygen saturation documented: 84
Oxygen saturation observations on room air: 33
Staff scheduled on Flatirons unit: 1
Nurses scheduled on Flatirons unit: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Reported staffing shortages impacting shower provision and assisted with showers |
| RN #1 | Registered Nurse | Reported shower scheduling and documentation issues |
| CNA #7 | Certified Nurse Aide | Reported workload challenges and shower room availability issues |
| CNA #8 | Certified Nurse Aide | Reported flexible shower scheduling and documentation challenges |
| DON | Director of Nursing | Provided information on staffing, shower preferences, and infection control education |
| NHA | Nursing Home Administrator | Provided census, staffing, and infection control information |
| LPN #1 | Licensed Practical Nurse | Provided information on Resident #75's behaviors and care |
| LEC | Life Engagement Coordinator | Provided information on dementia care and Resident #75's behaviors |
| SDC | Staff Development Coordinator | Provided infection control training and education records |
| CNA #2 | Certified Nurse Aide | Observed PPE use and provided information on infection control practices |
Viewing
Loading inspection reports...
