Federal inspectors found the facility's Director of Nursing acknowledged the training gap during a December complaint investigation. The DON said a floor nurse would typically provide step-by-step instructions to residents and certified nursing assistants for safe transfers and walking, but confirmed no structured training program existed specifically for CNAs on orthostatic hypotension fall prevention.
Orthostatic hypotension occurs when blood pressure drops suddenly upon standing, causing dizziness and falls. The condition requires specific safety protocols that should have been implemented based on at least one resident's fall history upon admission.
The DON told inspectors all residents in the facility were considered at risk for falls. Staff were aware of general fall prevention measures in place throughout the building.
The inspection revealed a gap between the facility's recognition of fall risks and its preparation of frontline staff. While the facility identified residents requiring specialized fall prevention protocols, it failed to ensure nursing assistants received the targeted training necessary to implement those safety measures effectively.
Federal inspectors cited the facility for failing to provide adequate fall prevention training, finding minimal harm or potential for actual harm to residents. The violation affected few residents but highlighted systemic weaknesses in staff preparation for managing complex medical conditions that increase fall risk.
The facility's approach of relying on informal, case-by-case instruction from floor nurses rather than comprehensive training left nursing assistants without standardized knowledge of orthostatic hypotension management techniques.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale Greenwood Village from 2025-12-01 including all violations, facility responses, and corrective action plans.