Brookshire Post Acute
BROOKSHIRE POST ACUTE in DENVER, CO — inspection on October 16, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
her there was nothing wrong.
jeopardy to resident health or safety
RN #1 said she told LPN #3 Resident #1 needed to be sent out immediately to the hospital.
She said LPN #3 was consulting the AD
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookshire Post Acute
4660 E Asbury Cir Denver, CO 80222
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance and performance improvement (QAPI) program committee failed to identify and address concerns related to accidents and safety of residents in which the facility failed to ensure hot water temperatures did not exceed safe temperature ranges that rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.Findings include:I.
Cross-reference citationCross-reference F-F689:
The facility failed to ensure safe water temperatures, conduct and document a thorough assessment of a resident with a new skin condition and notify the resident's provider timely.II.
Staff interviewsThe nursing home administrator (NHA) and regional clinical resource #2 were interviewed together on 8/16/25 at 6:00 p.m.The NHA said the maintenance director (MTD) was a newer staff member and started working at the facility in August 2025.
The NHA said at that time, the Summit shower room was down and not working.
The NHA said the Summit shower not working impacted the facility because the facility only had one working shower instead of two.
The NHA said the MTD did take the temperature of the Summit shower on approximately 9/4/25 or 9/5/25, prior to the residents using the shower.Regional clinical resource #2 said she preferred the facility include water management to their QAPI minutes and review them at the QAPI meeting then further review everything submitted in TELS.
The NHA said the QAPI committee met monthly.
The NHA said each interdisciplinary team (IDT) member was to submit assigned information that he, the NHA, reviewed prior to the QAPI meeting.
The NHA said the medical director attended the QAPI meeting and the IDT was required to attend.
Regional clinical resource #2 and the NHA were interviewed together a second time on 10/16/25 at 6:00 p.m.
The NHA said the paper audit tool created to monitor water temperatures was to be turned into him for review.
The NHA said he would then scan the audit into the computer for an electronic record and keep the paper copy in the facility's plan of the correction binder.
The NHA said all temperature monitoring would be sent to him for review.
The NHA said the MTD knew he was supposed to be monitoring water temperatures but he did not record them.
The NHA said facility staff could enter a work order into the TELS system (electronic submission system) that would be sent to maintenance to accept.
Facility ID: