Brookshire Post Acute
Inspection Findings
F-Tag F0689
F 0689
her there was nothing wrong.
Level of Harm - Immediate 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
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookshire Post Acute
4660 E Asbury Cir Denver, CO 80222
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0867
F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
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BROOKSHIRE POST ACUTE in DENVER, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DENVER, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROOKSHIRE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.