The March 27 inspection of Lakewood Post Acute and Rehabilitation revealed multiple care coordination failures affecting residents requiring specialized medical services. The facility operates at 7395 W Eastman Place.
Resident #18 received oxygen therapy without the required physician's order specifying flow rates or treatment protocols. The assistant director of nursing told inspectors that hospital discharge paperwork should indicate correct therapies and flow rates, and that both a care plan and physician's order should exist for oxygen therapy.
She couldn't locate either document.
The director of nursing confirmed during a separate interview that oxygen use required both a physician's order and care plan. She called these documents "crucial for the staff to know what the residents' plan of care was."
Both administrators acknowledged that portable oxygen tanks should be turned on during use.
The facility also failed to complete critical communication forms for a dialysis patient with end-stage renal disease. Resident #75, over 65 years old, had been admitted with metabolic encephalopathy, congestive heart failure, kidney failure and diabetes. Cognitive assessments showed moderate impairments.
Since admission, Resident #75 received four dialysis sessions. Nurses failed to complete the required post-dialysis section of communication forms for all four treatments.
These forms serve as vital links between the nursing home and dialysis center. According to facility policy, nurses must document medication changes, vital signs, treatment responses, complications, nutritional management, and any declines in condition. The policy specifically requires monitoring the resident's vascular access site after each treatment to check for bleeding or other complications.
The dialysis communication book initially provided by registered nurse #1 contained only one form dated March 17, with the post-dialysis section incomplete. A second binder revealed additional incomplete forms from March 19, 21, and 24.
During the inspection, physicians ordered completion of pre and post-dialysis forms on March 26 — after inspectors identified the missing documentation.
Registered nurse #1 told inspectors that nurses were responsible for completing communication forms before residents left for dialysis and upon return. She said nurses needed to review forms for orders or complications, then complete the post-dialysis section.
The assistant director of nursing blamed the incomplete forms on agency staff providing care at the facility. However, the director of nursing clarified that while agency staff must review policy binders before working, facility staff remained responsible for ensuring form completion.
She emphasized the importance of communication forms so both the facility and dialysis center stay informed about residents' medical needs, condition changes, and physician recommendations.
The facility also failed to conduct annual performance reviews for five certified nursing assistants, some hired as far back as July 2023. CNA #2, CNA #4, CNA #5, and CNA #6 all started work in July 2023 without receiving required annual evaluations. CNA #7, hired in March 2024, also lacked performance documentation.
Facility policy mandates annual job performance reviews for all employees, with written evaluations containing supervisory remarks, suggestions, training recommendations, and goals. These reviews determine promotions, transfers, wage increases, and identify quality improvement needs.
The director of nursing confirmed that none of the five nursing assistants had received annual performance reviews or completed in-service education based on review outcomes.
Federal regulations require nursing homes to observe each nurse aide's job performance and provide regular training. The facility's September 2024 policy specified that performance evaluations should occur after 90-day probationary periods and annually thereafter.
When inspectors requested annual performance reviews on March 25, the facility couldn't provide documentation for any of the five nursing assistants. Some had worked without evaluation for over 18 months.
The violations occurred at a facility caring for residents requiring complex medical interventions. Resident #75's conditions — including kidney failure requiring thrice-weekly dialysis, heart problems, and cognitive impairment — demanded careful coordination between multiple care providers.
Missing communication after dialysis treatments could delay recognition of complications like access site bleeding, fluid overload, or medication adjustments. The resident's moderate cognitive impairment, scoring 10 out of 15 on mental status assessments, made accurate staff documentation even more critical.
The oxygen therapy violation affected a different resident whose identity wasn't specified in inspection records. Operating oxygen equipment without physician orders or care plans creates risks for both under-treatment and over-treatment, particularly dangerous for residents with respiratory or cardiac conditions.
All violations received "minimal harm or potential for actual harm" classifications from federal inspectors. The oxygen and dialysis care deficiencies affected few residents, while the performance review failures affected some staff members.
The facility's regional director of clinical services provided policies during the inspection, including undated hemodialysis procedures and September 2024 performance evaluation requirements. The timing of policy revisions relative to ongoing care failures wasn't addressed in inspection records.
Resident #75 continued receiving dialysis treatments during the inspection period, with physicians finally ordering proper communication form completion on March 26. The facility's acknowledgment that agency staff contributed to documentation gaps highlighted ongoing staffing challenges affecting specialized care coordination.
The assistant director of nursing's immediate promise to obtain oxygen orders after inspector questioning suggested the violation had persisted for an undetermined period before detection.
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.
Additional Resources
- View all inspection reports for Lakewood Post Acute and Rehabilitation
- Browse all CO nursing home inspections