Lakewood Post Acute: Oxygen, Medical Device Failures - CO
LAKEWOOD, CO - Federal inspectors documented critical failures in oxygen management and medical device oversight at Lakewood Post Acute and Rehabilitation during a March 2025 survey, finding residents received oxygen therapy without physician orders and used therapeutic devices for months without proper medical authorization.
Critical Oxygen Management Failures Documented
During the March 27, 2025 inspection, surveyors discovered that Resident #18, an individual with documented oxygen dependency and morbid obesity, was receiving continuous oxygen therapy without any physician's order on file. The resident, who scored 15 out of 15 on cognitive assessments indicating full mental capacity, was observed on multiple occasions with oxygen equipment that was either improperly configured or not functioning.
On March 24, inspectors found the resident sitting in his wheelchair with a nasal cannula connected to a portable oxygen tank that was not turned on. When questioned, the resident stated he was "unsure about the oxygen concentration setting." This represents a fundamental breakdown in respiratory care management, as oxygen-dependent residents require precise flow rates to maintain adequate blood oxygen levels while avoiding the risks of oxygen toxicity.
The facility's own Oxygen Administration policy explicitly states that "oxygen is administered under orders of a physician, except in the case of an emergency." Despite this clear requirement, record reviews revealed no physician's order existed for this resident's oxygen therapy throughout his stay. The assistant director of nursing acknowledged during interviews that physician orders and care plans should be in place for all oxygen therapy, yet admitted she could not locate either document for this resident.
Medical Device Used Without Authorization for Ten Months
A second major violation involved Resident #15, a 66-year-old with severe bilateral knee contractures resulting from rheumatoid arthritis and osteoporosis. Physical therapy records indicated the resident had been using bilateral knee extension braces for contracture management since May 29, 2024. However, no physician's order for these devices existed until March 26, 2025 - during the actual survey - meaning the splints were used without medical authorization for nearly ten months.
The resident's contractures were severe, with observations documenting her "laying on her right side with her legs bent with her heels touching her back." Despite therapy documentation showing the resident wore knee splints for up to six hours daily, this critical treatment was never incorporated into her comprehensive care plan. The resident told surveyors she "did not like them because the splints caused her pain," raising additional concerns about proper monitoring and adjustment of the devices.
The director of rehabilitation initially claimed that physical therapy "had just started using a splint with the resident," directly contradicting medical records showing ten months of documented use. When confronted with this discrepancy, she suggested uncertainty about whether physician orders were required because the resident was paying privately rather than through insurance - a distinction that has no bearing on medical authorization requirements.
Understanding the Medical Implications
Oxygen therapy without proper physician oversight creates multiple serious risks. Incorrect flow rates can lead to hypoxemia (insufficient oxygen in the blood), causing confusion, cardiac stress, and potential organ damage. Conversely, excessive oxygen administration can result in oxygen toxicity, particularly dangerous for residents with certain lung conditions. The observation of a non-functioning portable oxygen tank is particularly concerning - an oxygen-dependent resident without functioning equipment faces immediate risk of respiratory distress, altered mental status, and potentially life-threatening complications.
For contracture management, unauthorized use of splinting devices without physician oversight eliminates crucial safeguards. Contractures require careful monitoring as aggressive splinting can cause pain, skin breakdown, or circulation problems. The facility's failure to obtain proper orders for ten months meant no physician evaluated whether the splinting program was appropriate, whether adjustments were needed based on the resident's pain complaints, or whether alternative treatments should be considered. Proper medical supervision would include regular assessments of skin integrity, circulation checks, and modifications based on the resident's tolerance and progress.
Systemic Failures in Professional Standards
The violations represent failures to meet basic professional standards of quality care. The facility's own policies required physician orders for oxygen therapy, yet staff at multiple levels - from nurses to directors - failed to ensure this fundamental requirement was met. The director of nursing acknowledged that "these documents were crucial for the staff to know what the resident's plan of care was," yet the facility operated without them.
The confusion among staff about basic requirements was evident throughout the investigation. One nurse stated that oxygen flow rates should be documented in the medication administration record, while another mentioned a report sheet updated by the assistant director of nursing. This lack of standardization in critical respiratory care documentation increases the risk of errors and inconsistent care delivery.
Additional Issues Identified
Beyond the primary violations, inspectors documented concerning gaps in care planning and documentation. Resident #15's minimum data set assessment failed to indicate any assistive or therapeutic devices despite months of documented splint use. The comprehensive care plan for this resident included general interventions for arthritis but made no mention of contracture management or splinting protocols.
Staff interviews revealed widespread confusion about responsibility for medical device orders, with the director of rehabilitation incorrectly suggesting that payment source might affect medical authorization requirements. The facility conducted an audit during the survey to ensure all residents using oxygen had appropriate care plans, indicating reactive rather than proactive quality assurance.
The inspection also identified a pattern of inadequate communication between departments, with therapy services implementing treatments without ensuring proper physician authorization or nursing care plan updates. Multiple staff members, including licensed practical nurses who had worked with residents for over a year, were unaware of whether required physician orders existed for treatments they were helping to implement.
These violations occurred at Lakewood Post Acute and Rehabilitation, located at 7395 W Eastman Place in Lakewood, Colorado. The facility's failure to ensure basic medical oversight for critical treatments including oxygen therapy and therapeutic devices placed vulnerable residents at risk for serious complications.
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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