Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boulder Canyon Health And Rehabilitation during CMS and state inspections, most recent first.
Unsafe and Unsanitary Shower Rooms: The facility failed to maintain three shower rooms in safe, sanitary, and working condition. Surveyors observed continuous leaks from shower head tubing, wet and sticky floors, black substance in silicone caulking, and damaged flooring in one shower room with cracked, peeling surfaces and an incomplete drain cover. An R and staff discussed the issues, and the NHA acknowledged the wet floor and open door could pose a slip risk for wandering residents.
Shower Room Ventilation Fans Were Not Operational: Surveyors found that three shower rooms lacked adequate outside ventilation because the exhaust fans were not working or had no air flow. The 200 hallway shower room had a fan that was initially off and later ran with a loud whirring noise, the secure unit shower room had no air flow and no window, and the 600 hallway shower room fan would not pull a tissue toward it. The NHA and maintenance staff observed the conditions during the survey, and the maintenance resource said the issue caused discomfort from foul odors and steam.
Surveyors found the secured unit had a poorly maintained environment with flickering and nonworking lights, damaged blinds in the common area and resident rooms, chipped paint, missing drywall, wall holes, and missing bathroom tiles. Multiple rooms and bathrooms also lacked hand towels, and staff said some issues were not reported or were only addressed after surveyors identified them.
Failure to provide behavioral health support for a resident with depression, suicidal ideations, and psychosocial distress. The resident, who had multiple serious medical conditions and was cognitively intact, said he did not want to live in the facility, thought about killing himself, and became very distraught after his sister died. Records showed a mood care plan and a physician order for psych eval/treatment, but there was no documentation of ongoing psych services, no update to the mood care plan after a suicide lethality assessment, and staff interviews confirmed inconsistent monitoring and no current behavioral health follow-up.
Failure to Provide a Vegan Diet That Met Nutritional Needs: A cognitively intact resident with malnutrition and other diagnoses had a documented vegan preference, but the facility did not have an RD-developed vegan menu or documentation showing his menu met estimated calorie, protein, and fluid needs. The resident reported that facility meals were often prepared with salt or oil and that he could only eat breakfast there, while his sister brought food daily for lunch and dinner. Staff confirmed he relied on outside food for most meals, and the RD stated there was no vegan menu with nutritional calculations to ensure his needs were met.
Infection control failures were observed when a sharps container in a shower room was found overflowing with used razors and additional razors were left on a cabinet beneath it. Staff interviews showed nurses were responsible for managing the container, and one LPN said it had been full for about a week before it was changed. In a separate event, staff entered a COVID-19 positive resident’s room without proper N95 use, and visitors entered the room wearing surgical masks instead of N95s, while nearby staff did not intervene.
The facility failed to maintain proper infection control practices, as staff did not consistently follow PPE protocols when entering and exiting droplet precaution rooms, and vital signs machines were not sanitized correctly between uses. Observations showed that an LPN, CNA, and NP did not adhere to PPE guidelines, and a CNA used ineffective alcohol wipes instead of approved sanitizing wipes for equipment disinfection.
The facility failed to ensure that a resident received proper treatment during a resuscitation attempt by not utilizing the emergency crash cart, delaying the call to EMS, and not having a licensed nurse remain with the resident until EMS arrived. The resident, who had severe cognitive impairment and multiple medical conditions, experienced a life-threatening change of condition, but essential resuscitation equipment was not used, and there was a lack of proper documentation and delegation of tasks.
Unsafe and Unsanitary Shower Rooms
Penalty
Summary
The facility failed to provide a safe, sanitary, functional, and comfortable environment in three of four shower rooms. During observations, the 200 hallway shower room, the secure unit shower room, and the 600 hallway shower room had ongoing maintenance and sanitation problems, including continuous dripping from shower head tubing, wet floors, and black substance observed in the silicone caulking. In the 200 hallway shower room, the door was held open with a gait belt tied to the door handle and shower railing while the floor remained wet with a pool of water in the middle. In the secure unit shower room, the floor was also wet and sticky because of the dripping shower head tubing. The 600 hallway shower room had additional damage. The flooring was cracked and peeling with an uneven surface, the caulking was damaged and in some areas ripped or torn out, and the shower drain cover did not fully cover the drain. A hard white substance was observed built up on the drain. Resident #99 said the 600 hallway shower room flooring needed to be updated because it was cracked and peeling, and he stated the facility would not listen to his concerns. He also said he was the only resident bothered by the floor because he was the only resident who stood and independently showered. Staff interviews showed the maintenance resource believed the dripping water was expected from backflow valves and initially described the black substance as residue. He also stated he did not believe harm could be caused by the shower floor remaining wet and said he did not know whether the damaged flooring in the 600 hallway shower room was a sanitizable surface. The NHA observed the leaking shower head tubing and agreed the wet shower floor with the door held open could have been a risk for wandering residents to slip and fall. The report states the maintenance repairs were not conducted until the concerns were brought to the facility's attention during the survey.
Shower Room Ventilation Fans Were Not Operational
Penalty
Summary
The facility failed to ensure adequate outside ventilation by means of windows or mechanical ventilation in three of four shower rooms because the ventilation fans were not operational. During the initial walkthrough, surveyors observed that the 200 hallway shower room had no air flow from the fan, the secure unit shower room had no air flow and felt muggy and hot, and the 600 hallway shower room was also muggy and hot. The report states that the facility’s policy required adequate outside ventilation by windows, mechanical ventilation, or both. The maintenance director and maintenance resource were interviewed during the survey and confirmed problems with the shower room ventilation. In the secure unit shower room, the maintenance resource found no air flow. In the 200 hallway shower room, he located the fan switch and turned it on, at which point the fan operated with a loud whirring noise and was said to need repair. The maintenance resource also stated that the secure unit shower room should have an operational fan because there was no window, and that the issue caused discomfort related to foul odors and steam. Surveyors continued to observe ventilation problems over the next several days. The 200 hallway shower room still had no air flow, the secure unit shower room remained without air flow, and the 600 hallway shower room fan would not suck a tissue held up to it. The NHA observed these conditions and said he would need to follow up with maintenance regarding how often the shower rooms were checked. The report also states that the shower room repairs were not conducted until the concerns were brought to the facility’s attention during the survey.
Unsafe and Poorly Maintained Secured Unit Environment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, and comfortable environment on the secured unit. During observations, surveyors found flickering and nonworking ceiling and bathroom lights, hallway light covers with dark particles, chipped paint and missing drywall near the nurses’ station and common area entrance, and multiple resident rooms with blinds that had missing or broken slats. The common area blinds were also observed with many missing and broken slats, and one room had a missing ceiling light cover. Surveyors also observed repeated environmental concerns in resident rooms and bathrooms, including white paint splotches on bathroom walls, holes in walls, paint coming off near the floor, dried brown liquid marks on a bedroom wall, and missing bathroom wall tiles. In one room, 16 tiles were missing from the bathroom wall and adjacent tiles were sticking out with sharp edges. These conditions were observed across multiple rooms on the secured unit over several days, and the maintenance director stated some repairs were not yet completed or were only being started during the survey after the facility became aware of the concerns. The facility also failed to ensure hand towels were available for residents’ use in their rooms and bathrooms. On multiple observations, several rooms on the secured unit did not have hand towels available, and staff stated the towels were supposed to be stocked and passed out by night shift, with day shift responsible if that did not occur. The maintenance records provided did not document the observed concerns, and staff interviews indicated some issues, including broken blinds and missing bathroom tiles, had not been reported or were not known to maintenance until surveyors identified them.
Failure to Provide Behavioral Health Support for Suicidal Ideation and Depression
Penalty
Summary
The facility failed to ensure a resident with mental health and psychosocial adjustment concerns received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing. The resident was cognitively intact, had diagnoses including a right above-knee amputation, ostomy, COPD, and chronic hepatitis C, and his mood assessment showed he felt down, depressed, and hopeless. He told staff he did not want to live in the facility, was very depressed about not being able to leave, had lost weight because he had lost interest in eating, and said he often thought about killing himself, including overdosing or obtaining a gun he believed might be in his stored belongings. The record showed a mood care plan identifying potential mood problems and noting that the resident would at times state he wished he was dead, with interventions including behavioral health consultants as needed and monitoring for depression, anxiety, or sad mood. However, after a suicide lethality assessment placed him on 15-minute safety checks, the mood care plan was not updated to reflect that assessment. The physician order to refer him to behavioral health for psychiatric and psychological evaluation and treatment as indicated did not result in documented psychological services in the resident’s record during the review period. The resident also experienced significant grief and distress after his sister died, and social services documented that he was very distraught and had been seen by behavioral health in the past but was not currently being seen. There was no documentation that behavioral health services were offered or provided in response to his distress over his sister’s death. Staff interviews confirmed the resident expressed depression, refusal of care, poor appetite, and suicidal statements, but one CNA was not aware of any monitoring for depression or suicidal ideations. The social services director stated the resident had previously seen a mental health provider, but services ended and were not followed up because of an insurance issue.
Failure to Provide a Vegan Diet That Met Nutritional Needs
Penalty
Summary
The facility failed to provide Resident #94 with a nourishing, palatable, well-balanced diet that met his daily nutritional and special dietary needs while taking his vegan preferences into account. The resident, who was cognitively intact and required set-up assistance with eating, had diagnoses including a left humerus fracture, OCD, digestive system disease, and unspecified protein-calorie malnutrition. His physician orders listed a regular diet with thin liquids and documented a preference for a vegan diet, along with instructions to honor his dietary choices and provide dietary education as needed. Record review showed the resident’s nutrition care plan and assessment acknowledged his vegan preference and estimated nutritional needs, but there was no documentation that the facility assessed whether its menu provided adequate nutrition for him. The weekly menu did not include a vegan menu developed by an RD, and the alternative food item menu only contained highlighted or handwritten vegetarian items without serving sizes, ingredients, or calculated nutritional values. The RD stated she did not have a vegan menu for the resident that included nutritional calculations to ensure his estimated needs were met. During interview, the resident stated he had been a strict vegan for many years and ate only plain boiled or steamed vegetables, beans, and grains without animal products, vegetable oils, salt, or spices. He reported that the facility’s food was often served with added salt or oil and that the only meal he could eat there was breakfast, consisting of applesauce, almond milk, and oatmeal. He said his sister brought him food every day for lunch and he ate the leftovers for dinner. His sister confirmed she was bringing food daily because she feared he would lose weight and said other facilities had been able to accommodate his diet. Staff interviews confirmed the resident generally ate only breakfast from the facility and relied on food brought by his sister for lunch and dinner.
Infection Control Failures With Overfilled Sharps Container and Improper PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in a 600 hallway shower room when the sharps container was observed overflowing with used razors, with additional used razors sitting on top of a cabinet beneath the container. The facility policy stated that contaminated sharps containers were to be sealed and replaced when they were 75-80% full, but the container in the shower room was found overfilled during survey observation. Staff interviews indicated that nurses were responsible for managing the sharps containers, and one LPN stated the container had been full for about a week before it was changed during the survey. The facility also failed to ensure appropriate PPE use when staff entered a COVID-19 positive resident's room. During observation, a CNA approached the room wearing a surgical mask, gown, gloves, and goggles, but did not don an N95 respirator before entering. Another CNA later approached the same room wearing a surgical mask and initially asked whether she had to gown up; she was told to wear a mask and gloves, and she later put on an N95 mask over her surgical mask before entering the room. The infection preventionist stated that staff entering a COVID-19 positive resident room should wear an N95 mask and that a surgical mask should not be worn beneath the N95 mask. Visitors were also observed entering the COVID-19 positive resident room wearing surgical masks and gloves rather than N95 masks. Staff nearby did not intervene or encourage N95 use before the visitors entered the room. Interviews with nursing staff and the infection preventionist confirmed that an N95 mask should be worn in the COVID-19 positive room, and the infection preventionist stated she had not spoken with the family about masking preferences or asked whether staff had inquired with the visitors about their masking preferences.
Infection Control Deficiencies in PPE Use and Equipment Sanitization
Penalty
Summary
The facility failed to adhere to proper infection control protocols, specifically in the use of personal protective equipment (PPE) when entering and exiting droplet precaution rooms. Observations revealed that healthcare personnel, including an LPN, CNA, and an NP, did not consistently follow the required procedures for donning and doffing PPE. For instance, the LPN exited a droplet precaution room without removing her gown and gloves inside the room, and the CNA did not wear eye protection as required. Additionally, the NP was observed wearing an N95 mask over a surgical mask, which does not provide an adequate seal. The facility also failed to ensure that vital signs machines were properly sanitized between uses. A CNA was observed using alcohol wipes, which are not the recommended method for disinfecting medical equipment, to clean the vital signs machine between resident uses. The facility's policy requires the use of approved sanitizing wipes, such as Sani wipes, to ensure effective disinfection of equipment between each resident use. Interviews with staff, including the DON, confirmed that there was a lack of adherence to the facility's infection control policies. The DON acknowledged that the staff were expected to follow specific procedures for PPE use and equipment disinfection, but these were not consistently followed. The DON also noted that there was an inservice held about PPE use, indicating that staff had been informed of the correct procedures, yet compliance was not observed during the survey.
Failure to Utilize Emergency Equipment and Timely Call EMS During Resuscitation
Penalty
Summary
The facility failed to ensure that Resident #9 received treatment and care in accordance with professional standards of practice during a resuscitation attempt. Specifically, the emergency crash cart containing essential resuscitation equipment and a backboard was not utilized. Additionally, there was a delay in calling emergency medical services (EMS) for immediate assistance when Resident #9 experienced a life-threatening change of condition, and a licensed nurse did not remain with the resident until EMS arrived. Resident #9, an 82-year-old with severe cognitive impairment, respiratory failure, dementia, Parkinson's disease, and dysphagia, experienced a change of condition that included nausea, vomiting, abnormal vital signs, and shortness of breath. Despite the presence of a bag-mask device and airway supplies on the emergency crash cart, these were not used during the resuscitation attempt. The nursing progress note did not indicate the exact time 911 was called, and there was no further documentation regarding the resuscitation timeline. Interviews with staff revealed that RN #1, who was with Resident #9, failed to delegate the task of calling 911 to other staff members present in the room. Instead, RN #1 left the room to make the call herself, leaving the resident unattended. During the resuscitation, chest compressions were performed without the use of a backboard, and no bag-mask device was used to provide breathing assistance. The Director of Nursing (DON) confirmed that there was no root cause analysis or investigation conducted after the unexpected death of Resident #9, and staff did not document the events as they occurred.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boulder
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frasier Meadows Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Boulder Post Acute | 2.3 mi | ★★★★★ | 15 | 0 |
| Winding Trails Post Acute | 3.2 mi | ★★★★★ | 4 | 0 |
| Coal Creek Post Acute & Assisted Living | 8.2 mi | ★★★★★ | 14 | 0 |
| Accel At Longmont Health And Rehab, Llc | 10.7 mi | ★★★★★ | 47 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.