Oakwood Care and Rehabilitation: Dementia Care Failure - CO
That July 18, 2024 incident, documented in a nursing progress note timestamped 3:55 p.m., is at the center of a federal complaint inspection that cited Oakwood Care and Rehabilitation for failing to provide person-centered dementia services. The violation, tagged F744, was recorded during an inspection completed January 29, 2025.
The progress note described Resident 2 approaching multiple residents, screaming and cursing at them without apparent cause. Staff directed the resident away from the group and offered food and conversation. The assistant director of nursing and the on-call provider were notified.
That was it.
The notification of a supervisor and a doctor is not the same as a plan. Person-centered dementia care requires understanding why a resident in cognitive decline behaves the way they do on a given afternoon, and then responding in a way that addresses the person, not just the moment. Offering food and redirecting someone away from the room they walked into is a crowd-control response. It is not a care response.
What the inspection record does not contain is any indication that Oakwood Care had developed, or attempted to develop, a behavioral care plan tailored to Resident 2. There is no documentation of a review of what preceded the episode, what Resident 2 may have been experiencing, or what the facility intended to do differently if it happened again. The ADON was called. The on-call provider was called. And the note ends.
The other residents in that common space that afternoon are also part of this picture. They were the ones being screamed and cursed at. For residents with their own cognitive impairments, that kind of encounter can be genuinely frightening, and the fear does not necessarily resolve when the person doing the screaming is walked out of the room. Their experience does not appear in the inspection findings at all.
Dementia does not make a person's distress less real. It often makes it harder to communicate. A resident who approaches others screaming may be in pain, or disoriented, or frightened, or responding to something in the environment that nobody else has identified yet. The clinical work of dementia care is figuring out which of those things is true for a specific person on a specific day, and building a response around that person's history, preferences, and needs.
What Oakwood Care documented instead was a generic intervention, food and talking, applied to a situation that called for something more considered. The facility then notified two supervisors and, apparently, moved on.
Federal inspectors reviewed that progress note and determined it reflected a failure to provide person-centered dementia services. The citation does not describe a catastrophic event. Nobody was physically harmed in the way the inspection record describes it. But the standard for dementia care is not the absence of physical injury. It is whether the facility is actually treating a person with dementia as a person, with a specific history and specific needs, rather than as a behavioral problem to be redirected toward a snack.
Oakwood Care and Rehabilitation has not, based on what the inspection record contains, offered any public accounting of what it has done since July 18 to ensure Resident 2 has a care plan that reflects who that person is and what they need.
The progress note from that afternoon is a thin document. Three sentences describing what happened, a notation of who was called. It captures a moment of distress for at least one resident, possibly several, and records the facility's response in full: food, conversation, two phone calls.
What it does not capture is what comes next for Resident 2.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO was cited for violations during a health inspection on January 29, 2025.
The violation, tagged F744, was recorded during an inspection completed January 29, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.