Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: Dec 1, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication management, fall prevention, respiratory care, and food safety in the nursing home.
Findings
The facility failed to ensure timely administration of prescribed medications, proper fall prevention interventions for a resident with orthostatic hypotension, consistent and proper use and cleaning of CPAP machines, and maintenance of sanitary conditions in the kitchen including food storage and ice machine cleanliness.
Deficiencies (4)
F 0684: The facility failed to ensure Resident #2 received all prescribed medications upon admission due to pharmacy delays, resulting in missed doses of Rifaximin, Risperidone, and Midodrine.
F 0689: The facility failed to provide adequate fall prevention for Resident #2 with orthostatic hypotension, including failure to implement prescribed use of an abdominal binder and lack of staff education on the condition.
F 0695: The facility failed to ensure Residents #1 and #4 received consistent CPAP therapy and failed to properly clean and store CPAP equipment according to physician orders and manufacturer instructions.
F 0812: The facility failed to maintain sanitary conditions in the kitchen, including unclean surfaces, improperly stored and labeled food items, and an ice machine with visible debris and lack of professional deep cleaning documentation.
Report Facts
Missed medication doses: 3
CPAP order delay: 8
Ice machine cleaning frequency: 1
Fall incident date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication administration, fall prevention training, and CPAP cleaning procedures. |
| DON | Director of Nursing | Interviewed about medication delays, fall prevention measures, CPAP care, and staff training. |
| Dietary Manager | Dietary Manager | Interviewed about kitchen sanitation, food labeling, and ice machine maintenance. |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 28, 2024
Visit Reason
Routine inspection of Brookdale Greenwood Village nursing home to assess compliance with regulatory standards including resident care, medication management, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to honor resident choice in bathing schedules, inadequate personal hygiene assistance, inconsistent treatment and care documentation, unsafe bed positioning for fall-risk residents, ineffective pain management, medication administration errors, improper medication storage, hydration issues, lack of adaptive dining equipment, poor food handling and labeling, infection control lapses, and failure to administer pneumococcal vaccination despite consent.
Deficiencies (12)
F 0561: The facility failed to honor residents' right to self-determination by not offering shower schedule choices to residents #1 and #23, assigning shower days by room number without resident input.
F 0677: The facility failed to provide necessary personal hygiene services to residents #49 and #23, including nail care and oral hygiene assistance.
F 0684: The facility failed to assess and document vital signs prior to administering blood pressure medication for Resident #47 and failed to obtain weights as ordered for Resident #16.
F 0687: The facility failed to provide appropriate foot care for Residents #49 and #16, resulting in overgrown and infected toenails.
F 0689: The facility failed to ensure beds were in the lowest position for fall-risk residents #6 and #41 when in bed, increasing risk of falls.
F 0697: The facility failed to provide effective pain management for Resident #216, including incomplete pain assessments, failure to identify pain location and goals, and inconsistent medication administration.
F 0761: The facility failed to ensure medication carts were locked when unattended, risking unauthorized access to medications.
F 0807: The facility failed to ensure residents #31 and #266 received adequate hydration and thickened liquids per physician orders, and failed to encourage fluid intake for Resident #31.
F 0810: The facility failed to provide adaptive dining equipment for residents #22 and #18 and failed to provide plate guards for Resident #1 as required.
F 0812: The facility failed to properly label and date food items and failed to handle ready-to-eat foods with appropriate hygiene in satellite kitchens.
F 0880: The facility failed to maintain an infection control program including proper cleaning procedures, PPE use, hand hygiene, resident hand hygiene before meals, and an adequate water management plan.
F 0883: The facility failed to administer pneumococcal vaccination to Resident #6 despite consent being provided.
Report Facts
Residents reviewed: 35
Medication administrations of midodrine given outside parameters: 26
Instances of Resident #31 consuming 0-25% of offered fluids: 37
BIMS score: 5
BIMS score: 13
BIMS score: 15
BIMS score: 10
BIMS score: 13
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and vital signs assessment finding for Resident #47 |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and medication cart locking findings |
| LPN #4 | Licensed Practical Nurse | Named in personal hygiene, hydration, and thickened liquids findings |
| LPN #5 | Licensed Practical Nurse | Named in personal hygiene and foot care findings |
| LPN #8 | Licensed Practical Nurse | Named in pain management findings for Resident #216 |
| CNA #2 | Certified Nurse Aide | Named in personal hygiene, hydration, and thickened liquids findings |
| CNA #3 | Certified Nurse Aide | Named in personal hygiene and foot care findings |
| CNA #4 | Certified Nurse Aide | Named in oral hygiene documentation finding |
| CNA #5 | Certified Nurse Aide | Named in hand hygiene observation during meal delivery |
| Dietary Manager | Dietary Manager | Named in food labeling and hand hygiene findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including shower scheduling, medication administration, infection control, and vaccination |
| Infection Preventionist | Infection Preventionist | Named in infection control and vaccination findings |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding adherence to PPE protocols for residents with influenza.
Findings
The facility failed to maintain an infection control program by not requiring appropriate PPE, specifically the use of surgical gowns, for staff entering rooms of residents symptomatic and positive for influenza. Observations and interviews confirmed staff did not consistently follow PPE guidelines.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff did not wear the required surgical gown when entering a resident room with droplet precautions for influenza.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
Annual survey inspection of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 3
Date: Dec 21, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, pressure ulcer care, dialysis care, and other aspects of nursing home care.
Findings
The facility failed to ensure residents' rights to self-determination regarding bathing preferences for two residents, failed to provide appropriate pressure ulcer care for one resident, and failed to provide safe and appropriate dialysis care for one resident. Deficiencies included inconsistent shower provision, failure to implement wound care interventions, and incomplete dialysis communication and assessments.
Deficiencies (3)
F 0561: The facility failed to honor residents' rights to self-determination by not providing consistent showers according to preferences and routine schedules for Residents #164 and #33.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers by not ensuring Resident #55 wore Prevalon boots and by not implementing care plan interventions to promote wound healing.
F 0698: The facility failed to provide safe, appropriate dialysis care for Resident #60 by not ensuring ongoing communication with the dialysis center, incomplete pre and post dialysis documentation, and failure to assess and document the resident's response to dialysis.
Report Facts
Residents reviewed for bathing preferences: 26
Residents reviewed for pressure injuries: 26
Residents reviewed for hemodialysis: 26
Shower refusals documented for Resident #164: 5
Shower refusals documented for Resident #33: 4
Wound measurements for Resident #55 right heel: 5
Wound measurements for Resident #55 left heel: 2.7
Dialysis treatments missing pre/post forms: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided facility policies, interviewed regarding shower and wound care deficiencies, and confirmed dialysis communication issues. | |
| Licensed Practical Nurse #1 | Interviewed about shower schedules and refusal documentation. | |
| Certified Nurse Aide #1 | Interviewed about shower schedules and refusal documentation. | |
| Certified Nurse Aide #3 | Interviewed about reminding staff to apply Prevalon boots to Resident #55. | |
| Registered Nurse #3 | Interviewed about dialysis communication forms and procedures. |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 31, 2021
Visit Reason
Routine inspection to assess compliance with healthcare regulations including medication administration, catheter care, respiratory care, medication storage, food service safety, and staff training.
Findings
The facility failed to ensure timely physician notification for late medication administration, proper catheter care and physician orders, correct oxygen therapy administration, medication error prevention, proper medication storage and labeling, sanitary food handling practices, and adequate staff training on abuse prevention and dementia management.
Deficiencies (7)
F580: Facility failed to notify physicians of medications administered more than 60 minutes late for Residents #35 and #41 over a two month period.
F0690: Facility failed to obtain physician orders and develop comprehensive care plans for residents with indwelling catheters (#23 and #26), and failed to provide appropriate catheter care.
F0695: Facility failed to administer oxygen therapy as ordered for Residents #5, #8, #14, and #38, with oxygen concentrators set incorrectly.
F0759: Medication administration error rate was 19.23% due to injectable medication error and multiple late medication administrations for residents #35, #41, and #102.
F0761: Facility failed to remove expired and discontinued medications and blood collection equipment timely, and failed to properly label and store loose tablets and biologicals in medication carts and storage rooms.
F0812: Facility failed to ensure food service staff used proper hand hygiene and glove changes when handling and plating ready-to-eat foods, risking contamination during multiple meal services.
F0943: Facility failed to provide annual abuse identification and prevention training to 115 of 166 employees and dementia management training to 138 of 166 employees.
Report Facts
Medication administration error rate: 19.23
Instances of late medication administration: 29
Instances of late medication administration: 59
Instances of late medication administration: 46
Residents receiving oxygen therapy: 29
Residents receiving incorrect oxygen flow: 15
Expired Lantus insulin pen days past use: 10
Expired blood collection tubes: 18
Expired influenza vaccines: 32
Staff without annual abuse training: 115
Staff without annual dementia management training: 138
Report
December 1, 2025
Report
March 28, 2024
Report
January 30, 2024
Report
March 27, 2023
Report
December 21, 2022
Report
August 31, 2021
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