Provider Name: BRIARWOOD HEALTH CARE CENTER
Address: 1440 VINE ST, DENVER, CO 80206
Phone: (303) 399-0350
County: Denver (150)
Ownership Type: For profit - Corporation
Certified Beds: 201
Average Residents Per Day: 82.3 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: LIFE CARE CENTERS OF AMERICA, INC.
First Approved Date: February 17, 1989
Affiliated Entity: LIFE CARE CENTERS OF AMERICA (311)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 2 ()
QM Rating: 4 ()
Long Stay QM Rating: 3 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 4 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.26477, LPN Staff Hours Per Day: 0.8743, RN Staff Hours Per Day: 0.6627, Licensed Staff Hours Per Day: 1.5370
Total Nurse Staff Hours Per Day, per resident: 3.80180
Weekend Nurse Staff Hours: 3.44392, Weekend RN Staff Hours: 0.5154
PT Staff Hours Per Day, per resident: 0.0604
Nurse Staff Turnover: 54.8, Nurse Turnover Note:
RN Turnover: 50.0, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9343, Case Mix LPN Hours Per Day: 0.6685, Case Mix RN Hours Per Day: 0.3108
Adjusted Nurse Aide Hours Per Day, per resident: 2.38526, Adjusted LPN Hours Per Day: 0.9651, Adjusted RN Hours Per Day: 0.8034
Total Adjusted Nurse Hours Per Day, per resident: 4.11284
Adjusted Weekend Nurse Hours Per Day, per resident: 3.72568
Health Survey Dates and Scores: Cycle 1: 2023-05-09 (Score: 106), Cycle 2: 2022-03-15 (Score: 80), Cycle 3: 2021-01-14 (Score: 60)
Total Weighted Health Score: 89.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 67148.25, Payment Denials Number: 0, Total Penalties Number: 3
Location and GPS: 1440 VINE ST,DENVER,CO,80206 (39.7392, -104.962)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Provide care by qualified persons according to each resident's written plan of care.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-31
Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-02
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-31
Type: Health, Deficiency: Provide activities to meet all resident's needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-01
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-02
Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-02
Type: Health, Deficiency: Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-02
Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-01
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-01
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-02
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-07
Type: Health, Deficiency: Provide activities to meet all resident's needs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-13
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-13
Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-13
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Past Non-Compliance on 2022-03-15
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-13
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-13
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-02-10
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-23
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-21
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-25
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-21
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-26
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-25
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-25
Type: Fire Safety, Tag: 0511, Version: New
Description: Have properly installed electrical wiring and gas equipment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-23
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-30
Type: Fire Safety, Tag: 0911, Version: New
Description: Meet requirements for the installation and maintenance of electrical systems.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-27
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-21
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0531, Version: New
Description: Have elevators that firefighters can control in the event of a fire.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-06-07
Type: Fire Safety, Tag: 0161, Version: New
Description: Use approved construction type or materials.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-19
Type: Fire Safety, Tag: 0226, Version: New
Description: Have horizontal exits used in accordance with safety requirements.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-27
Type: Fire Safety, Tag: 0231, Version: New
Description: Provide large enough exits.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0233, Version: New
Description: Install resident room doors of proper design and width.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0241, Version: New
Description: Have correct number of accessible exits for each story.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0251, Version: New
Description: Conform to length requirements for dead end corridors.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0271, Version: New
Description: Have exits that are accessible at all times.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0291, Version: New
Description: Install emergency lighting that can last at least 1 1/2 hours.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0321, Version: New
Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-19
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-19
Type: Fire Safety, Tag: 0331, Version: New
Description: Construct fire resistant interior walls.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0351, Version: New
Description: Install an approved automatic sprinkler system.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-21
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-16
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0362, Version: New
Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0363, Version: New
Description: Install corridor and hallway doors that block smoke.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0372, Version: New
Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-19
Type: Fire Safety, Tag: 0511, Version: New
Description: Have properly installed electrical wiring and gas equipment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-16
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0751, Version: New
Description: Have restrictions on the use of flammable curtains.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0753, Version: New
Description: Have restrictions on the use of highly flammable decorations.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0912, Version: New
Description: Have power receptacles that are properly grounded.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0919, Version: New
Description: Meet requirements for the use of electrical equipment.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-16
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-31
Type: Fire Safety, Tag: 0927, Version: New
Description: Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-04-19