Brookdale Greenwood Village

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent and treat pressure injuries for one (#20) of two residents out of 34 sample residents. Resident #20, who was dependent on staff for all care and mobility and was known to be at risk for skin breakdown, was admitted to the facility on [DATE] with a right hip surgical incision, but did not have any pressure injuries. The facility did not implement interventions to offload the resident's heels or provide a low-air loss mattress upon the resident's admission to the facility. Additionally, the facility failed to conduct a Braden Scale assessment (a tool utilized for predicting pressure ulcer injury risk) upon the resident's admission to the facility. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#28) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure supervision was provided, as determined in an assessment, to prevent a fall for Resident #28 that resulted in fractures. Resident #28 was admitted on [DATE] with diagnoses of sepsis (infection of the blood), unsteadiness on feet, generalized muscle weakness, repeated falls and other Alzheimer's disease. Resident #28, was identified as a fall risk and had a history of repeated falls. Resident #28 was found outside by facility staff on 3/29/26. Resident #28 was bleeding from her mouth and had pain when trying to bend her knees. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in two of two kitchenettes. Specifically, the facility failed to ensure staff used proper hand hygiene during meal service.

Inspectors wroteBased on record review and interviews, the facility failed to complete grievance forms consistently to address and promptly resolve resident grievances. Specifically, the facility failed to effectively address, resolve, and demonstrate the facility's response to group grievances.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically, the facility failed to:-Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP);-Ensure an effective process was in place to ensure staff were aware of which residents were on EBP; and,-Ensure nursing staff cleaned blood pressure cuffs between residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#4) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included risks versus benefits and side effects of prescribed psychotropic medications.

Inspectors wroteBased on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in one of five medication carts. Specifically, the facility failed to ensure expired and discontinued medications were removed from the medication cart and disposed of.

Inspectors wroteBased on record review and interviews, the facility failed to meet all requirements for the provision of hospice are for one (#7) of one resident reviewed for hospice out of 34 sample residents. Specifically, the facility failed to demonstrate adequate communication with the hospice staff and facility staff regarding care that the hospice staff provided during visits.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#6 and #30) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to:-Ensure Resident #6 received the pneumococcal vaccine when consent was given; and,-Ensure Resident #30 was offered the flu vaccine.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement policies and procedures related to immunizations for two (#2 and #7) of five residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to:-Ensure the COVID-19 vaccine was provided to Resident #2 after she received education and gave consent; and,-Ensure Resident #7's medical record documented if the resident was offered the COVID-19 vaccine when available and documentation documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional food safety standards in the main kitchenSpecifically, the facility failed to ensure:-The kitchen was kept in a sanitary manner;-Perishable foods were properly labeled, stored, and maintained; and, -The ice machine was maintained in a sanitary condition.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of three residents received the highest practicable treatment and care in accordance with professional standards of practice of seven sample residents. Specifically, the facility failed to ensure all prescribed medications including medications to treat cirrhosis of the liver (scarred and damaged liver that prevents it from working properly), high blood pressure, and a chronic mental health disorder were ordered and obtained from the pharmacy to administer to the resident upon admission.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#2) of three residents reviewed for accident hazards/ falls out of seven sample residents. Specifically, the facility failed to:-Ensure Resident #2, who had a history of falls, was appropriately assessed at admission to determine needed interventions to prevent ongoing falls; -Ensure appropriate fall prevention interventions were in place; and,-Ensure all clinical staff were educated on Resident #2's orthostatic hypotension diagnosis (a sudden drop in blood pressure that happens when a resident changes position from lying or seated position to a standing position causes dizziness and/or fainting) which puts the resident at a high risk for falls.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#1 and #4) of three residents who required respiratory care received care consistent with professional standards of practice out of seven sample residents. Specifically, the facility failed to:-Ensure Resident #1 and Resident #4 were provided their physician-ordered continuous positive airway pressure (CPAP) treatment consistently; and, -Ensure Resident #4's CPAP machine was cleaned and stored properly.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide accessible dining equipment and utensils for residents who need them for three (#22, #18, and #1) of three residents reviewed for adaptive equipment out of 35 sample residents. Specifically, the facility failed to: -Provide adaptive drinking equipment for Resident #22 and Resident #18; and, -Provide plate guards for Resident #1.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two satellite kitchens. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely; and -Ensure ready to eat foods were handled appropriately.

Inspectors wroteBased on record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections on two of two units. Specifically, the facility failed to: -Ensure housekeeping staff cleaned from cleaner to dirtier areas; -Ensure housekeeping changed gloves and performed hand hygiene between cleaning the bathroom and bedroom; -Provide accurate isolation precaution and appropriate use of personal protective equipment (PPE); -Ensure staff performed hand hygiene; -Ensure residents were offered hand hygiene prior to eating; and, -Follow the water management plan I. Housekeeping failures A. [...]

Inspectors wroteBased on record review and interviews, the facility failed to offer choices to residents for two (#1 and #23) of three residents reviewed for activities of daily living (ADL) out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and #23 received showers consistently according to their choice of frequency.

Inspectors wroteBased on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for two (#49 and #23) of four residents reviewed for services to maintain highest practicable quality of life out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #49 received assistance for nail care; and, -Ensure Resident #23 received assistance to maintain oral hygiene.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#47 and #16) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the failed to: -Assess and document Resident #47's blood pressure and heart rate consistently prior to administering blood pressure medications; and, -Obtain weights according to the physician's orders for Resident #16.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure two (#49 and #16) of four residents reviewed for ancillary services out of 35 sample residents received proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure foot care was provided for Resident #49 and Resident #16.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for two (#6 and #41) of three residents out of 35 residents Specifically, the facility failed to ensure Resident #6 and Resident #41, who were both at risk for falls, had their beds in the lowest position when the residents were in bed.

Inspectors wroteBased on record review, interviews and observations, the facility failed to provide an effective pain management regime in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#216) out of 35 sample residents. Specifically, the facility failed to: -Ensure a pain assessment was completed that identified the onset, the presence and duration of pain for Resident #216; -Ensure to identify the resident's goal for pain management and acceptable level of pain for Resident #216; -Ensure to identify a new pain location for Resident #216; and, -Ensure to monitor the effectiveness of the pain medication for Resident #216.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#265) of four residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to follow physician ordered parameters for medication administration for Resident #265's midodrine (a medication used to treat low blood pressure).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards on two of 6 medication carts. Specifically, the facility failed to ensure medication carts were locked appropriately when they were unattended.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained adequate hydration for two (#31 and #266) of two residents reviewed for hydration out of 35 sample residents. Specifically, the facility failed to: -Encourage fluid intake for Resident #31; and, -Provide thickened liquids per physician's orders for Resident #31 and Resident #266.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#6) of five residents reviewed for immunizations out of 35 sample residents. Specifically, the facility failed to administer the pneumococcal vaccination after consent was provided for Resident #6.

Inspectors wroteBased on observations, record review staff interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to post the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for one of two resident rooms. Specifically, the facility failed to wear appropriate personal protective equipment (PPE) in a resident room was symptomatic and positive for influenza.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#164 and #33) out of five residents reviewed for bathing preferences out of 26 sample residents. Specifically, the facility failed to provide consistent showers for Resident #164 and Resident #33 according to their preferences and routine shower schedules.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#55) of two residents reviewed for pressure injuries received care and services, consistent with professional standards of practice, to prevent development and promote healing of pressure injuries, out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #55's Prevalon (offloading) boots were in place; and, -Implement interventions (Prevalon boots and air mattress) to Resident #55's care plan to promote wound healing.

Inspectors wroteBased on observations, record review and interviews, the facility failed ensure ongoing assessment of the resident's condition by monitoring for complications before and after dialysis treatments for one (#60) out of one resident reviewed for hemodialysis of 26 sample residents. Specifically, the facility failed to ensure for Resident #60: -The facility received ongoing communication and collaboration with the dialysis facility regarding the dialysis care and services; -Facility staff completed the pre and post dialysis communication forms for seven out of eleven dialysis treatments; -Documentation in the medical record was consistent with pre and post dialysis condition and weight measurements; and, -Evaluate the resident's response to the dialysis session.