Cycle 1
Health 2024-02-06 · Fire 2024-02-06
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Boulder, CO
Boulder Canyon Health And Rehabilitation
5-star overall rating with 4-star inspections with 5 recent health deficiencies
4685 Baseline Rd, Boulder, CO
(303) 494-0535
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
1.92
Nurse aide staffing
Weekend hours
2.91
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
93.5%
5.3 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
94.7%
1.7 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.4%
1.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 9.1% |
7.4%
1.7 pts worse
|
11.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.0%
0.9 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
11.2%
2.9 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.9% |
20.6%
4.3 pts worse
|
16.7%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.0% |
15.2%
0.8 pts worse
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
14.6%
6 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.8%
0.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.3% |
22.4%
9.1 pts better
|
19.8%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
3.7%
2.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.2% |
76.4%
10.8 pts better
|
81.7%
5.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.8%
0.3 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
75.6%
10 pts better
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
20.3%
3 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-03 · Fire 2022-11-03
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-07-20 · Fire 2021-07-20
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-25
E · Potential for more than minimal harm
2024-02-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-02-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-02-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-25
E · Potential for more than minimal harm
2022-11-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-03
E · Potential for more than minimal harm
2022-11-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-03
D · Potential for more than minimal harm
2022-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-03
D · Potential for more than minimal harm
2022-11-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-03
D · Potential for more than minimal harm
2022-11-03
F920 · Environmental Deficiencies
Health
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.
Corrected 2022-12-03
F · Potential for more than minimal harm
2021-07-20
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-20
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-17
E · Potential for more than minimal harm
2021-07-20
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 2021-08-13
E · Potential for more than minimal harm
2021-07-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-20
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-07-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-07-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-07-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-28
D · Potential for more than minimal harm
2021-07-20
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-08-13
Penalties and ownership
What sits behind the stars
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Dunyon, David
Corporate Officer · Individual
Horton, Christopher
Operational/Managerial Control · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Lauritzen, Ray
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Frasier Meadows Health Care Center
Boulder, CO
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
#2
Boulder Post Acute
Boulder, CO
2-star overall rating with 2-star inspections with abuse icon flag with $9,113 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Winding Trails Post Acute
Boulder, CO
1-star overall rating with 1-star inspections with abuse icon flag with $101,829 in total fines with 10 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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