Oakwood Care: Cold Food, Expired Items Found - CO

Federal inspectors conducting a complaint investigation found the facility failed to serve food at proper temperatures and maintained unsafe storage practices throughout multiple areas during their January 29 visit.

Four residents interviewed described persistent problems with meal temperatures. Resident #28 said the food was bad. Resident #10 told inspectors food was often served cold and the facility seemed to run out of common food items. Resident #3 said every once in a while her food arrived warm to her room, otherwise the food was always cold. Resident #16 said the food was not being prepared properly because they microwaved the vegetables, and the food was always served cold.

Inspectors observed meal service on January 27 for nearly two and a half hours. Assembly of resident meal trays for the 400 hall room delivery started at 1:20 p.m. Four minutes later, the facility ran out of zucchini and cooked broccoli to serve for the remainder of the meal.

The test tray was covered with a room delivery base instead of a plate cover or insulated dome lid. By 1:43 p.m., when the first room tray was delivered, the cover had partially fallen off the test tray leaving the food exposed. The test tray remained partially uncovered during transport to unit 700.

When inspectors evaluated the test tray at 1:53 p.m., after the last resident had been served, they found the broccoli at 102 degrees, the chicken breast at 120 degrees, and the penne pasta at 102 degrees. The cake had no icing and the pasta was overcooked and soggy.

The dietitian resource told inspectors the plates used for the 400 hall room trays were not placed in the plate warmer prior to meal assembly. She said plates placed in the plate warmer were used for room trays and the plates left on the shelf at room temperature were usually used for the dining room.

The facility had created a dietary improvement plan in October 2024 that included food temperatures as a correction action item. However, additional plates were not purchased until the survey period in late January.

Kitchen storage violations were extensive. Inspectors found four sealed containers of deli-style potato salad with use-by dates of January 7. A plastic package of hot dogs was unsealed and dated January 20. A plastic squeeze bottle containing an unidentified sauce was unlabeled and undated. Two thawed raw pork roasts sat in a clear container with no pull dates or expiration dates.

An open bottle of burgundy cooking wine with an expiration date of December 13, 2023 was discovered in the kitchen.

The drink station refrigerator contained commercially packaged apple slices with an expiration date of January 1 — the package was swollen and bloated. A slice of cake sat unwrapped and unlabeled in the freezer. Multiple containers of yogurt had expiration dates ranging from December 18, 2024 to January 18, 2025. Two containers of milk had sell-by dates of November 15, 2024. Five pitchers of juice were unlabeled and undated.

Nourishment rooms throughout the facility showed similar problems. The 400 hall refrigerator contained frozen pasta with a best-before date of July 2024 with no resident name or date written on the package. One package of corn tortillas had "9/27" written on it. Fresh grapes had no resident name or date. A jar of green chile sauce had a name but no open date.

Despite posted signs stating food left past 72 hours would be thrown away and that dietary staff would check food daily, the expired items remained in place from January 27 to January 28.

In the 500 hall nourishment refrigerator, inspectors discovered vaccines stored improperly in the butter conditioner — a shelf on the inside of the door with a clear cover. One dose of Prevnar vaccine and two doses of tuberculin vaccine, both labeled with resident names, sat in sealed plastic bags. The butter conditioner had a plastic lid that did not completely seal and had no labels indicating medications were to be stored there.

The director of nursing said medications were not typically stored in the nourishment refrigerators and were removed after the discovery.

Staff interviews revealed confusion about food safety responsibilities. The dietitian resource said it was the responsibility of all dietary staff to pay attention to food labels and that staff should write pull dates when items were removed from the freezer. She said cleaning unit refrigerators were on the dietary staff checklist to be completed every week.

Licensed practical nurse #2 said she would discard a jar of green chile because it did not have a date written on it, though the printed date on the jar showed 2026.

The facility also violated infection control protocols for a resident with high infection risk. Resident #12 had an indwelling suprapubic catheter and stage 4 pressure injuries requiring enhanced barrier precautions during high-contact care activities.

On January 27, the droplet precaution sign was removed from Resident #12's door and the personal protective equipment bin was no longer outside the room. Staff providing care failed to wear required gowns during high-contact activities.

A physical therapist entered the resident's room at 1:09 p.m. to perform exercises without putting on protective equipment. A speech language pathologist also entered without proper gear at 1:42 p.m.

The next day, two certified nurse aides provided perianal care to the resident without donning gowns, though they wore gloves. The resident had a wound dressing on his right hip that was pulling up along the edges with visible drainage.

Staff interviews revealed widespread confusion about infection control requirements. One certified nurse aide said she was not familiar with any special infection precautions required for Resident #12. Another said he was unaware of any need to wear special protective equipment except gloves when performing care.

The assistant director of nursing initially removed the droplet precautions sign and equipment bin from the resident's door because the resident had no current active infections and he was uninformed about enhanced barrier precautions.

The director of nursing acknowledged Resident #12 should have had proper signage and equipment outside his room to alert staff of his high infection risk status. The regional clinical resource said the facility would conduct an enhanced barrier precautions audit, including staff education and training.

The violations affected food safety for multiple residents and infection control for at least one high-risk resident with serious wounds and medical devices.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Oakwood Care and Rehabilitation from 2025-01-29 including all violations, facility responses, and corrective action plans.

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