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🔎 Boulder Canyon Health And Rehabilitation

Inspection Results


Inspection Overview

Boulder Canyon Health And Rehabilitation has been cited for a total of 74 deficiencies since we began saving each survey.

In Colorado, the average facility has **44.88 deficiencies** per survey cycle. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-11-03
Correction Date: 2022-12-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-11-03
Correction Date: 2022-12-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2022-11-03
Correction Date: 2022-12-03
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Perform COVID19 testing on residents and staff.

Survey Date: 2022-06-01
Correction Date: 2022-06-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Perform COVID19 testing on residents and staff.

Survey Date: 2022-06-01
Correction Date: 2022-06-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-07-20
Correction Date: 2021-08-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-07-20
Correction Date: 2021-08-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-07-20
Correction Date: 2021-08-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2021-07-20
Correction Date: 2021-08-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2021-07-20
Correction Date: 2021-08-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-07-20
Correction Date: 2021-08-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-07-20
Correction Date: 2021-08-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2021-07-20
Correction Date: 2021-08-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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

Survey Date: 2021-07-20
Correction Date: 2021-08-13
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-09
Correction Date: 2021-01-12
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2020-09-17
Correction Date: 2020-10-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: G

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-19
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: G

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: G

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

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2020-01-16
Correction Date: 2020-02-15
Category: Environmental Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**