LAKEWOOD, CO - Federal inspectors documented serious gaps in medical documentation and staff supervision at Lakewood Post Acute and Rehabilitation during a March 2025 inspection, including incomplete dialysis communication records and missing oxygen therapy orders that left vulnerable residents without proper care coordination.
Missing Oxygen Therapy Documentation Places Resident at Risk
Inspectors discovered that Resident #18 received supplemental oxygen without any physician's order or care plan documenting the therapy. During the March 27, 2025 inspection, facility leadership acknowledged they could not locate either required document in the resident's medical record.
The Assistant Director of Nursing (ADON) confirmed during an interview that proper protocols required both a physician's order specifying oxygen therapy details and flow rates, as well as a comprehensive care plan. She noted that hospital discharge paperwork typically provides this information, which should then be transcribed into facility orders. When inspectors pointed out the missing documentation, she acknowledged the oversight and committed to entering the order immediately.
The Director of Nursing reinforced during her interview that oxygen therapy documentation was "crucial for the staff to know what the residents' plan of care was." She also noted that portable oxygen equipment should be activated when in use—a basic safety protocol that ensures residents receive prescribed therapy.
Oxygen therapy requires precise medical oversight because improper flow rates can cause serious complications. Too little oxygen fails to adequately support respiratory function, potentially leading to hypoxia and organ damage. Conversely, excessive oxygen can cause oxygen toxicity, particularly dangerous for patients with certain lung conditions. Without documented orders specifying the prescribed flow rate and usage schedule, nursing staff lack the guidance needed to provide safe, consistent care.
The absence of a care plan compounds this risk. Care plans serve as the roadmap for all aspects of resident treatment, ensuring continuity across nursing shifts and enabling staff to recognize and respond to changes in condition. When oxygen therapy lacks a care plan, staff cannot properly monitor effectiveness, document responses to treatment, or identify complications requiring physician notification.
Systematic Failures in Dialysis Communication
The inspection revealed that Resident #75, who required hemodialysis three times weekly for end-stage renal disease, consistently received incomplete communication documentation between the facility and the dialysis center. Over a one-week period spanning four dialysis sessions on March 17, 19, 21, and 24, facility nurses failed to complete the required post-dialysis assessment section on communication forms.
The 85-year-old resident, admitted with metabolic encephalopathy, congestive heart failure, end-stage renal disease, and type 2 diabetes, had moderate cognitive impairments. His complex medical conditions made thorough communication between care providers especially critical.
The facility's own Hemodialysis policy required licensed nurses to document comprehensive information on dialysis communication forms, including medication administration, vital signs, laboratory values, advance directives, nutritional and fluid management, dialysis treatment responses, adverse reactions, access site complications, condition changes, and fall risks. The policy specifically stated that nurses must "monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications."
Despite these clear requirements and a physician's order dated March 24 directing staff to "obtain vital signs pre dialysis and post dialysis every shift every Monday, Wednesday and Friday," the post-dialysis sections remained blank across all four treatment dates reviewed. Only during the survey itself, on March 26, did the facility enter an order to "fill out pre/post dialysis form for dialysis Monday, Wednesday and Friday."
When interviewed, RN #1 acknowledged that nurses held responsibility for completing communication forms both before residents departed for dialysis and upon their return. She confirmed the forms required review for new orders or complications, followed by completion of the post-dialysis section. The ADON suggested the gaps might relate to agency staff working in the facility, though she acknowledged it remained the floor nurses' responsibility to ensure proper completion.
The Director of Nursing explained that these communication forms served as the vital link between the facility and dialysis center, alerting both parties to medical needs, condition changes, or recommendations requiring physician discussion. She noted that while agency staff reviewed facility policies in an orientation binder, facility staff bore ultimate responsibility for form completion.
This communication breakdown created multiple clinical risks. Post-dialysis monitoring identifies life-threatening complications including excessive bleeding from vascular access sites, severe blood pressure drops, abnormal heart rhythms, and fluid imbalances. Dialysis patients face heightened fall risk due to blood pressure changes and fatigue following treatment. Without documented post-treatment assessments, the facility could not establish baseline status, recognize deterioration, or respond appropriately to complications.
The incomplete documentation also meant the facility lacked critical information about dialysis center recommendations, medication adjustments, or concerns requiring follow-up. For a resident with congestive heart failure, careful fluid management becomes paramount—excess fluid removal during dialysis can dangerously lower blood pressure, while insufficient removal worsens heart failure. The communication gaps left facility staff unable to coordinate this delicate balance.
Annual Performance Reviews Completely Absent
Inspectors found that five certified nurse aides working at the facility had never received annual performance evaluations despite facility policy and federal requirements mandating yearly reviews. The affected CNAs had hire dates ranging from July 2023 to March 2024, meaning some had worked at the facility for nearly two years without formal performance assessment.
Federal regulations require facilities to observe each nurse aide's job performance and provide regular training based on these observations. The facility's own Performance Evaluations policy, revised in September 2024, stated that "job performance of each employee shall be reviewed and evaluated at least annually" following an initial 90-day probationary evaluation.
The policy outlined that performance evaluations should contain supervisory remarks and suggestions, identify any needed additional training, and establish goals. These evaluations serve multiple purposes: determining promotions, transfers, wage increases, and most importantly, improving work quality and identifying training needs.
When inspectors requested documentation on March 25 for CNA #2 (hired July 20, 2023), CNA #4 (hired July 30, 2023), CNA #5 (hired July 20, 2023), CNA #6 (hired July 20, 2023), and CNA #7 (hired March 18, 2024), the facility could not produce any annual performance reviews. The Director of Nursing confirmed that none of these five CNAs had received annual evaluations and consequently had not completed in-service education based on review outcomes.
This represents a fundamental failure in quality assurance and staff development. Performance reviews serve as the mechanism for identifying knowledge gaps, skill deficiencies, and training needs among direct care staff. Without these evaluations, the facility cannot systematically assess whether CNAs maintain competency in infection control, proper transfer techniques, skin care, nutritional support, or recognizing and reporting condition changes.
The absence of performance-based training also means the facility lacks data to guide its in-service education program. Rather than targeting training to actual observed needs, education becomes generic and potentially misses critical skill gaps affecting resident care and safety.
Additional Issues Identified
Beyond the major violations, inspectors documented the facility's failure to ensure compliance with its own policies regarding communication and documentation standards. The facility employed agency nursing staff but lacked effective systems to ensure these temporary workers completed required documentation to the same standards as permanent staff.
The inspection also revealed reactive rather than proactive approaches to documentation compliance, with orders and policies created only after surveyors identified deficiencies rather than through ongoing quality assurance monitoring.
Facility Information: - Facility Name: Lakewood Post Acute and Rehabilitation - Location: 7395 W Eastman Pl, Lakewood, CO 80227 - Inspection Date: March 27, 2025 - Type: Health Inspection
The violations were classified as causing minimal harm or having potential for actual harm. Federal and state regulators will continue monitoring the facility's corrective actions to ensure sustained compliance with care and safety standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Post Acute and Rehabilitation from 2025-03-27 including all violations, facility responses, and corrective action plans.
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