Inspection Reports for
Brookshire Post Acute
4660 E ASBURY CIR, DENVER, CO, 80222-4723
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
329% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Enforcement
Deficiencies: 2
Date: Oct 16, 2025
Visit Reason
The inspection was conducted due to a serious incident involving a resident who sustained second degree burns from excessively hot water during a shower, prompting an investigation into water temperature safety and facility compliance.
Findings
The facility failed to monitor and control hot water temperatures in residents' rooms and shower rooms, resulting in a resident sustaining second degree burns over 8% of his body. The facility also failed to promptly assess and notify the physician about the resident's skin condition and did not educate staff on safe water temperatures until after the incident.
Deficiencies (2)
F 0689: The facility failed to ensure hot water temperatures in residents' rooms and one shower room did not exceed safe limits, causing a resident to sustain second degree burns over 8% of his total skin surface. Staff did not complete timely assessments or notify the physician promptly. The facility failed to educate staff on safe water temperatures and did not monitor water temperatures consistently.
F 0867: The facility failed to implement an effective quality assurance program to identify and address safety concerns, including unsafe water temperatures that led to immediate jeopardy and serious harm to a resident.
Report Facts
Burn percentage: 8
Water temperature: 146
Water temperature: 150
Water temperature: 138
Water temperature: 136
Water temperature: 122
Water temperature: 118
Water temperature: 114
Water temperature: 112.6
Water temperature: 109.6
Water temperature: 107.6
Water temperature: 104.4
Resident rooms monitored: 34
Rooms monitored weekly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Notified nurse of resident's skin peeling during shower and provided shower to Resident #1. |
| LPN #2 | Licensed Practical Nurse | Responded to CNA #1's notification, looked at Resident #1's skin but did not complete full assessment or notify physician timely. |
| ADON | Assistant Director of Nursing | Assessed Resident #1's skin in shower room, took photo, but delayed documentation and notification. |
| RN #1 | Registered Nurse | Completed full body skin assessment at 7:30 p.m. on 10/10/25 and identified blisters. |
| LPN #3 | Licensed Practical Nurse | Documented vital signs and assisted in sending Resident #1 to hospital. |
| MTD | Maintenance Director | Responsible for monitoring water temperatures but failed to record checks after 8/15/25. |
| NHA | Nursing Home Administrator | Notified of immediate jeopardy and involved in plan of correction. |
| Regional Clinical Resource #1 | Clinical Resource | Provided staff education on safe water temperatures after incident. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 sustained second degree burns from excessively hot water during a shower in the facility's Summit shower room.
Complaint Details
The complaint investigation was triggered by an incident on 10/10/25 where Resident #1 sustained second degree burns due to excessively hot water (146°F) in the Summit shower room. The facility failed to monitor water temperatures since 8/15/25 and did not educate staff on safe water temperatures until the survey date. Immediate jeopardy was identified and removed after corrective actions including stopping shower use, plumbing repairs, staff education, and implementation of water temperature monitoring.
Findings
The facility failed to monitor and control hot water temperatures in residents' rooms and shower rooms, resulting in Resident #1 sustaining second degree burns over 8% of his body. The facility also failed to conduct timely assessments, notify the physician promptly, and educate staff on safe water temperatures. Immediate jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (4)
Failure to ensure hot water temperatures in residents' rooms and shower rooms did not exceed safe limits, resulting in Resident #1 sustaining second degree burns.
Failure to conduct a full body skin assessment and timely notify the physician regarding Resident #1's skin condition.
Failure to educate staff on safe bathing water temperatures and appropriate monitoring after the incident.
Failure to maintain effective quality assurance and performance improvement (QAPI) program to identify and address facility compliance concerns, including water temperature monitoring.
Report Facts
Burn percentage: 8
Water temperature: 146
Water temperatures: 118
Water temperature: 150
Water temperature: 120
Water temperature: 100
Number of resident rooms: 34
Water temperature monitoring frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Provided shower to Resident #1 and first noticed skin peeling. |
| LPN #2 | Licensed Practical Nurse | Responded to CNA #1's call, assessed Resident #1's skin but did not complete full assessment or notify physician timely. |
| ADON | Assistant Director of Nursing | Assessed Resident #1's skin on 10/10/25 but did not document until 10/11/25 and did not notify physician immediately. |
| RN #1 | Registered Nurse | Completed full body skin assessment at 7:30 p.m. on 10/10/25 and identified blisters. |
| NHA | Nursing Home Administrator | Notified of immediate jeopardy and provided plan to remove it. |
| MTD | Maintenance Director | Responsible for water temperature monitoring; admitted no documentation after 8/15/25. |
| Regional Clinical Resource #1 | Clinical Resource | Provided staff education on 10/16/25 regarding safe water temperatures. |
| RN #2 | Registered Nurse | Assisted CNAs with bathing and described unsafe water heating practices during hot water outage. |
| LPN #3 | Licensed Practical Nurse | Documented Resident #1's vital signs and assisted in sending resident to hospital. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medical record accuracy, and documentation practices at the nursing home.
Findings
The facility failed to ensure one resident received assistance with showers as ordered by the physician and failed to maintain accurate and consistent medical record documentation for another resident's toileting care. Staff interviews confirmed gaps in care planning and documentation practices.
Deficiencies (2)
F 0676: The facility failed to ensure Resident #113 received assistance with showers according to physician orders and lacked a care plan for ADLs including bathing. Documentation did not explain missed or refused showers.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #63, with inconsistent and unclear documentation of toileting care despite physician orders.
Report Facts
Sample residents reviewed: 30
Showers received by Resident #113 in April 2024: 3
Showers refused by Resident #113 in April 2024: 2
Showers received by Resident #113 in May 2024: 4
Showers refused by Resident #113 in May 2024: 0
Showers received by Resident #113 in August 2024: 4
Showers refused by Resident #113 in August 2024: 1
BIMS score for Resident #113: 6
BIMS score for Resident #63: 6
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medical record accuracy, and facility policies, including activities of daily living assistance and medical documentation.
Findings
The facility failed to ensure Resident #113 received assistance with showers according to physician orders and lacked a care plan for ADLs including bathing. Additionally, the facility failed to document Resident #63's toileting accurately and consistently, with inconsistent documentation methods preventing verification of compliance with physician orders.
Deficiencies (2)
Failed to ensure Resident #113 received assistance with showers in accordance with physician orders.
Failed to document Resident #63's toileting in an accurate and easy to understand manner.
Report Facts
Sample residents reviewed: 30
Resident #113 shower opportunities: 8
Resident #113 shower opportunities: 9
Resident #113 shower opportunities: 8
Resident #63 toileting frequency: 2
Resident #63 BIMS score: 6
Inspection Report
Routine
Deficiencies: 11
Date: Jan 16, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to resident rights, care planning, activities, dental services, staff training, food safety, environment, and documentation.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication, inadequate resolution of resident grievances, failure to provide timely Medicare non-coverage notices, incomplete care plans for anticoagulant use and dental needs, insufficient assistance with activities of daily living, lack of personalized activity programs, incomplete staff performance reviews and training, failure to provide dental services as needed, unsafe food storage and labeling practices, incomplete and inconsistent medical record documentation, and environmental maintenance issues in the laundry room.
Deficiencies (11)
Failed to obtain informed consent for use of antipsychotic medication for Resident #47.
Failed to provide prompt and effective resolution for resident council grievances regarding staff conduct.
Failed to provide timely written notification of Medicare Non-Coverage to Resident #60's representative.
Failed to develop comprehensive care plans addressing anticoagulant use for Resident #46 and dental needs for Resident #9.
Failed to ensure Resident #113 received assistance with showers as ordered.
Failed to provide personalized activity programs for Residents #32, #60, and #50.
Failed to complete annual performance reviews and provide required in-service training for CNAs #3, #4, #5, and #6.
Failed to assist Resident #14 in obtaining routine or emergency dental services.
Failed to prevent food contamination by improper storage of raw chicken near ready-to-eat foods, failed to discard expired food, and failed to properly label and date food items.
Failed to maintain complete and accurate medical records for Resident #63, including inconsistent documentation of toileting.
Failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry room with multiple maintenance issues.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
CNAs affected: 4
Residents affected: 1
Food items: 1
Residents affected: 1
Maintenance issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional director of clinical services #2 | Regional Director of Clinical Services | Interviewed regarding care plans, staff training, and deficiencies |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding multiple deficiencies including consent, grievances, training, and food safety |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, staff training, and documentation |
| Social Services Director | Social Services Director | Interviewed regarding grievances, dental services, and activities |
| CNA #3 | Certified Nurse Aide | Mentioned in relation to shower assistance and lack of performance review and training |
| CNA #4 | Certified Nurse Aide | Mentioned in relation to shower assistance and lack of performance review and training |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and labeling deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding environmental maintenance issues in laundry room |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 16, 2025
Visit Reason
Routine inspection of Brookshire Post Acute nursing home to assess compliance with federal and state regulations related to resident care, facility environment, staff training, and medical record accuracy.
Findings
The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication, inadequate resolution of resident grievances, untimely Medicare non-coverage notices, incomplete care plans for anticoagulant use and dental needs, insufficient assistance with activities of daily living, lack of personalized activity programs, incomplete nurse aide performance reviews and training, failure to provide dental services, unsafe food storage and labeling practices, incomplete and inconsistent medical record documentation, and environmental safety concerns in the laundry room.
Deficiencies (12)
F 0552: The facility failed to obtain informed consent from Resident #47 or their legal representative prior to administration of an antipsychotic medication.
F 0565: The facility failed to provide prompt and effective resolution for resident council members' repeated concerns about staff conduct, including rudeness and disrespect.
F 0582: The facility failed to provide timely written notification of Medicare Non-Coverage to Resident #60's legal representative, limiting appeal opportunities.
F 0656: The facility failed to develop comprehensive care plans for Resident #46's anticoagulant medication use and Resident #9's dental needs.
F 0676: The facility failed to ensure Resident #113 received assistance with showers as ordered by the physician, with incomplete documentation of refusals and missed showers.
F 0679: The facility failed to provide personalized activity programs for Residents #32, #60, and #50, with no documentation of participation in leisure or group activities.
F 0730: The facility failed to complete annual performance reviews and provide regular in-service education for CNAs #3 and #4.
F 0791: The facility failed to assist Resident #14 in obtaining routine or emergency dental services and lacked documentation of dental referrals or contact with the resident's representative.
F 0812: The facility failed to prevent food contamination by storing raw chicken above ready-to-eat foods, failed to discard expired gravy, and failed to label and date pureed food containers appropriately.
F 0842: The facility failed to maintain complete and accurate medical records for Resident #63, with inconsistent and unclear documentation of toileting care.
F 0921: The facility failed to maintain a safe, sanitary, and comfortable environment in the laundry room, with wall damage, peeling paint, and ceiling sheetrock issues.
F 0940: The facility failed to provide effective training for CNAs #3, #4, #5, and #6 in abuse, dementia management, behavioral health, infection control, communication, QAPI, compliance, ethics, and resident rights.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
CNAs: 2
CNAs: 2
Residents affected: 1
Expired food items: 1
Unlabeled food containers: 13
Resident toileting documentation symbols: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Named in findings for lack of annual performance review and in-service training |
| CNA #4 | Certified Nurse Aide | Named in findings for lack of annual performance review and in-service training |
| CNA #5 | Certified Nurse Aide | Named in findings for lack of required training prior to independent care |
| CNA #6 | Certified Nurse Aide | Named in findings for lack of required training prior to independent care |
| NHA | Nursing Home Administrator | Interviewed regarding multiple deficiencies including consent, training, and environment |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including consent, training, and documentation |
| RDCS #1 | Regional Director of Clinical Services | Interviewed regarding care plans and dental services |
| RDCS #2 | Regional Director of Clinical Services | Interviewed regarding care plans, training, and documentation |
| DM | Dietary Manager | Interviewed regarding food storage and labeling deficiencies |
| MS | Maintenance Supervisor | Interviewed regarding environmental concerns in laundry room |
| SSD | Social Services Director | Interviewed regarding dental services and resident grievances |
Inspection Report
Abbreviated Survey
Deficiencies: 12
Date: Jan 25, 2024
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with regulatory requirements and investigate specific complaints and concerns related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights, maintain a safe and homelike environment, prevent abuse, ensure proper placement and consent for secured unit residents, timely report and investigate abuse, provide restorative and ancillary services, prevent falls, manage medications properly, and maintain an effective quality assurance program.
Deficiencies (12)
F0550: The facility failed to ensure Resident #18's right to refuse care and maintain dignity during showering, exposing him in a see-through sheet to other residents.
F0584: The facility failed to maintain a clean, comfortable, and homelike environment, with multiple rooms and showers having odors, damage, and needed repairs.
F0600: The facility failed to protect Resident #27 from physical abuse by Resident #46 and failed to investigate and report the abuse to the State Agency.
F0603: The facility failed to ensure Resident #18 was free from involuntary seclusion in the secured unit without required assessments and representative consent.
F0609: The facility failed to timely report injuries of unknown origin (bruising and scratches) involving Resident #27 to the State Agency.
F0610: The facility failed to thoroughly investigate allegations of abuse involving bruising and scratches to Resident #27.
F0685: The facility failed to ensure Resident #50 was provided with an eye exam despite documented vision concerns and resident report of double vision.
F0688: The facility failed to provide restorative services to Residents #11 and #50 to maintain or improve range of motion and mobility, with restorative programs placed on hold or not initiated.
F0689: The facility failed to implement effective fall prevention interventions and supervision for Residents #13 and #53, including failure to update care plans and ensure use of assistive devices.
F0757: The facility failed to ensure Resident #55's drug regimen was free from unnecessary drugs by allowing acetaminophen doses exceeding recommended daily limits.
F0761: The facility failed to properly discard discontinued and expired medications on the medication cart and in the medication storage room.
F0867: The facility failed to maintain an effective Quality Assessment and Assurance Program (QAPI) to identify and correct ongoing deficiencies, including abuse prevention, secured unit placement, and restorative care.
Report Facts
Residents affected: 25
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 6
Acetaminophen maximum dose: 3000
Acetaminophen possible dose: 4950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident dignity, fall risk, and restorative care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident dignity, fall risk, and supervision |
| DON | Director of Nursing | Interviewed regarding abuse investigations, restorative care, fall prevention, medication management, and QAPI |
| RN #1 | Registered Nurse | Interviewed regarding abuse reporting, restorative care, and resident mood |
| DOR | Director of Rehabilitation | Interviewed regarding restorative services and therapy referrals |
| NHA | Nursing Home Administrator | Interviewed regarding QAPI and facility management |
| RPH | Registered Pharmacist | Interviewed regarding acetaminophen dosing |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 25, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations related to resident rights, safety, abuse prevention, care and treatment, medication management, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights to refuse care and dignity, maintain a safe and homelike environment, prevent and investigate abuse, ensure appropriate placement in secured units, provide restorative and ancillary services, prevent falls, manage medications properly, and maintain an effective quality assurance program.
Deficiencies (12)
Failed to ensure Resident #18's right to refuse a shower and provide dignity by covering him with a non-transparent sheet after showering.
Failed to maintain a clean, comfortable, and homelike environment; rooms and bathrooms had odors, needed repairs, and were not properly maintained.
Failed to protect Resident #27 from physical abuse by Resident #46 and failed to investigate and report the abuse to the State Agency.
Failed to ensure Resident #18 was free from involuntary seclusion in the secured unit without required assessments and consent.
Failed to timely report injuries of unknown origin (bruising and scratches) on Resident #27 to the State Agency.
Failed to conduct a thorough investigation of bruising and scratches on Resident #27 to rule out abuse.
Failed to ensure Resident #50 was provided with an eye exam despite documented vision problems and resident request.
Failed to provide restorative services to Residents #11 and #50 to maintain or improve range of motion and mobility.
Failed to implement effective fall prevention interventions and supervision for Residents #13 and #53, and failed to update care plans accordingly.
Failed to ensure Resident #55's drug regimen was free from unnecessary drugs by allowing excessive acetaminophen dosing beyond recommended limits.
Failed to properly store medications by retaining discontinued and expired medications on medication carts and in the medication storage room.
Failed to maintain an effective quality assurance and performance improvement program to identify and correct ongoing deficiencies, including abuse prevention, secured unit placement, and restorative care.
Report Facts
Residents affected: 25
Acetaminophen maximum daily dose: 4950
Acetaminophen recommended maximum daily dose: 3000
PHQ-9 severity score: 13
MDS mental status score: 2
MDS mental status score: 9
MDS mental status score: 0
MDS mental status score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident rights, fall risk, and restorative care |
| CNA #2 | Certified Nurse Aide | Observed and interviewed regarding Resident #18 dignity and Resident #13 fall risk |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and expired medications |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident rights, fall risk, and supervision |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding Resident #53 fall risk and supervision |
| RN #1 | Registered Nurse | Interviewed regarding abuse reporting, restorative care, and resident depression |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse investigations, restorative care, fall prevention, medication management, and QAPI |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding restorative and physical therapy services |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding QAPI and facility management |
| Registered Pharmacist | Registered Pharmacist | Interviewed regarding acetaminophen dosing and medication safety |
| Social Worker | Social Worker | Interviewed regarding secured unit placement and resident assessments |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of resident abuse, neglect, and failure to provide appropriate care at Brookshire Post Acute nursing home.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident-to-resident abuse, failure to report and investigate abuse allegations, and failure to provide appropriate care and treatment. The complaints were substantiated with findings of actual harm and minimal harm.
Findings
The facility failed to protect residents from abuse, failed to timely report and investigate allegations of abuse, and failed to provide appropriate treatment and care including medication administration, pressure ulcer care, and contracture management for several residents.
Deficiencies (6)
F0600: The facility failed to protect Resident #3 from physical abuse by Resident #6 despite knowledge of Resident #6's aggressive behaviors, resulting in actual harm with lacerations and bruising.
F0609: The facility failed to timely report suspected abuse and the results of investigations to proper authorities for Residents #1 and #4.
F0610: The facility failed to thoroughly investigate allegations of abuse for Residents #1 and #4, including failure to document investigations.
F0658: The facility failed to ensure blood pressure medication (Metoprolol) was consistently ordered and administered for Resident #3, with documented missed doses and medication not in stock.
F0686: The facility failed to provide timely assessment, treatment, and ongoing care for a newly developed unstageable pressure injury to Resident #1's coccyx, with treatment delayed four days and lack of person-centered care plan interventions.
F0688: The facility failed to properly assess and manage Resident #1's left elbow and left hand contracture, with no measurements, no preventative interventions in the care plan, and worsening contracture documented by staff and representative.
Report Facts
Measurement of Resident #3 injuries: 19
Measurement of Resident #3 injuries: 2.5
Measurement of Resident #3 injuries: 2
BIMS score: 6
BIMS score: 2
Medication missed doses: 3
Pressure injury wound size: 21
Pressure injury wound size: 8.3
Pressure injury wound size: 3.5
Pressure injury wound size: 4
Pressure injury wound size: 9
MDS mental status score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse investigations and medication management |
| Chief Operations Officer | Chief Operations Officer (COO) | Interviewed regarding abuse reporting and investigations |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding medication administration and resident monitoring |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding resident care and contracture observations |
| Regional Clinical Consultant | Regional Clinical Consultant (RCC) | Interviewed regarding wound care and contracture management |
| Wound Nurse | Wound Nurse (WN) | Interviewed regarding pressure injury assessment and treatment |
| Hospice Certified Nurse Aide | Hospice Certified Nurse Aide (HCNA) | Interviewed regarding resident contracture and repositioning |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of resident abuse, neglect, and failure to provide appropriate care at Brookshire Post Acute nursing facility.
Complaint Details
The complaint investigation was triggered by multiple allegations of resident abuse including physical abuse and neglect. The facility was found to have failed in protecting residents from abuse, failed to report and investigate abuse allegations timely, and failed to provide appropriate care and treatment to residents.
Findings
The facility failed to protect residents from abuse, failed to report and investigate allegations of abuse timely, and failed to provide appropriate treatment and care for residents including medication administration, pressure injury care, and contracture management.
Deficiencies (5)
Failed to protect Resident #3 from resident-to-resident physical abuse by Resident #6 despite known aggressive behaviors.
Failed to timely report suspected abuse and conduct thorough investigations for allegations involving Residents #1 and #4.
Failed to ensure blood pressure medication was consistently ordered and administered for Resident #3.
Failed to provide timely assessment and treatment for a newly developed unstageable pressure injury for Resident #1 and failed to ensure ongoing care and person-centered interventions.
Failed to properly assess and manage contractures for Resident #1, including failure to identify contractures in the care plan and implement preventative measures.
Report Facts
Residents reviewed for abuse: 7
Residents affected by abuse: 4
Length of Resident #3's leg laceration: 19
Length of Resident #3's thigh laceration: 2.5
Length of Resident #3's hand laceration: 2
BIMS score Resident #3: 6
BIMS score Resident #6: 2
Medication doses missed for Resident #3: 3
Pressure injury wound measurement: 36
Braden scale score Resident #1: Resident #1 was at moderate risk for pressure injuries.
MDS mental status score Resident #1: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse investigations and medication administration. |
| Chief Operations Officer | Chief Operations Officer (COO) | Interviewed regarding abuse reporting and investigations. |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding medication administration and abuse incident. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding responsibilities in resident altercations. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding abuse reporting and resident care. |
| Social Worker | Social Worker | Responsible for initial abuse investigations. |
| Hospice Certified Nurse Aide | Hospice Certified Nurse Aide (HCNA) | Interviewed regarding resident contracture and skin care. |
| Regional Clinical Consultant | Regional Clinical Consultant (RCC) | Interviewed regarding wound care and contracture management. |
| Wound Nurse | Wound Nurse (WN) | Interviewed regarding wound assessment and treatment. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding resident contracture and skin breakdown. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 29, 2022
Visit Reason
The survey was conducted as a recertification inspection to assess compliance with federal regulations including resident rights, abuse prevention, dementia care, medication administration, infection control, hospice care, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to protect residents from abuse, inadequate dementia care, medication errors, failure to maintain proper hospice communication, inadequate infection control practices, incomplete COVID-19 vaccination tracking, and ineffective quality assurance processes.
Deficiencies (11)
F578: The facility failed to ensure residents' rights to request, refuse, or discontinue treatment and to formulate advance directives, including accurate physician orders and documentation for code status and MOST forms for residents #39 and #262.
F600: The facility failed to protect eight residents from resident-to-resident sexual and physical abuse, including repeated sexual assaults by Resident #20 and failure to implement effective interventions.
F603: The facility failed to ensure five residents on the secure unit had required documentation for involuntary seclusion including physician orders, resident representative consents, and secure unit evaluations.
F0695: The facility failed to provide appropriate respiratory care for Resident #24 with a laryngectomy, lacking physician orders, respiratory assessments, and a current person-centered care plan.
F0744: The facility failed to provide appropriate treatment and services for five residents with dementia, including lack of person-centered behavioral interventions and failure to prevent resident-to-resident altercations.
F0759: The facility's medication error rate was 20%, including administration of medication without physician orders and failure to verify resident identity prior to medication administration.
F0760: The facility failed to keep Resident #15 free from significant medication errors, including nearly administering medications to the wrong resident without verifying identity.
F0849: The facility failed to maintain effective communication and collaboration with the hospice provider for Resident #53, including lack of timely documentation of hospice visits.
F0867: The facility failed to develop and implement effective quality assurance and performance improvement plans to address repeated deficiencies in abuse prevention and dementia care.
F0880: The facility failed to ensure proper wearing of masks and eye protection for staff during substantial community transmission of COVID-19, including a primary care physician observed without eye protection and wearing a cloth mask.
F0888: The facility failed to develop and implement a COVID-19 vaccination process that included all staff and contracted providers, with incomplete vaccination status tracking and missing data for outside providers.
Report Facts
Medication error rate: 20
Residents affected by abuse: 8
Residents affected by involuntary seclusion documentation issues: 5
Residents reviewed for dementia care deficiencies: 5
Hospice visit notes missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Primary Care Physician (PCP) #1 | Observed wearing cloth mask and no eye protection during facility visits. | |
| Licensed Practical Nurse (LPN) #2 | Observed medication administration errors and failure to verify resident identity. | |
| Registered Nurse (RN) #2 | Supervised medication administration and corrected medication errors. | |
| Director of Nursing (DON) | Interviewed regarding facility policies, quality assurance, and infection control. | |
| Medical Director (MD) | Interviewed regarding medication administration and quality assurance. | |
| Respiratory Therapist (RT) | Assessed Resident #24 and provided education on stoma care. | |
| Social Services Director (SSD) | Interviewed regarding behavior monitoring and secure unit placement. | |
| Nursing Home Administrator (NHA) | Interviewed regarding quality assurance and COVID-19 vaccination tracking. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Sep 29, 2022
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident rights, abuse, medication errors, infection control, and quality of care at Brookshire Post Acute nursing home.
Complaint Details
The complaint investigation revealed multiple issues including failure to protect residents from abuse, failure to provide appropriate care and documentation for residents with dementia and respiratory needs, medication errors, infection control lapses, and incomplete COVID-19 vaccination tracking for staff.
Findings
The facility failed to ensure residents' rights to refuse treatment and formulate advance directives, protect residents from resident-to-resident sexual and physical abuse, maintain proper documentation for secure unit placement, provide appropriate respiratory care for a resident with a laryngectomy, deliver person-centered dementia care, ensure medication error rates were below 5%, maintain effective communication with hospice providers, implement an effective quality assurance program, enforce infection prevention protocols including proper PPE use, and maintain a complete COVID-19 vaccination matrix for all staff including contracted providers.
Deficiencies (10)
Failed to ensure residents' rights to request, refuse, and discontinue treatment and to formulate advance directives for two residents.
Failed to protect eight residents from resident-to-resident sexual and physical abuse, including failure to implement effective interventions to prevent repeated sexual abuse by Resident #20.
Failed to ensure five residents on the secure unit had required documentation to justify restrictions including doctor orders, resident representative consents, and secure unit evaluations.
Failed to provide appropriate treatment and services to five residents diagnosed with dementia, including failure to provide person-centered approaches and behavior monitoring.
Medication error rate was 20% with five errors out of 25 opportunities, including administering medication without physician orders and incorrect dosing.
Failed to keep one resident free from significant medication errors, including nearly administering medications to the wrong resident.
Failed to maintain communication with hospice provider for one resident, including lack of documentation of hospice visits after 9/1/22.
Failed to develop and implement effective quality assurance and performance improvement plans to address repeated deficiencies in abuse prevention and dementia care.
Failed to ensure proper wearing of masks and eye protection for staff, including a primary care physician observed wearing a cloth mask and no eye protection during visits in resident areas.
Failed to develop and implement a COVID-19 staff vaccination process to address all facility staff including agency staff, with incomplete vaccination status documentation for outside providers.
Report Facts
Medication error rate: 20
Residents affected by abuse: 8
Residents affected by secure unit documentation failure: 5
Residents affected by dementia care deficiencies: 5
Hospice visit notes missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Involved in medication errors including administering medication without physician orders and nearly administering medications to the wrong resident. |
| RN #2 | Registered Nurse | Supervised medication administration and intervened to prevent medication errors. |
| PCP #1 | Primary Care Physician | Observed not wearing eye protection and wearing a cloth mask in resident areas; vaccination status not initially listed on facility matrix. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse prevention, medication administration, infection control, and hospice communication. |
| NHA | Nursing Home Administrator | Interviewed regarding quality assurance, infection control, vaccination matrix, and hospice communication. |
| DCO | Director of Clinical Operations | Interviewed regarding behavior tracking system and infection control. |
| MD | Medical Director | Interviewed regarding QAPI, medication administration, and secure unit placement. |
| SSD | Social Services Director | Interviewed regarding secure unit placement evaluations, behavior monitoring, and hospice communication. |
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