Oakwood Care: Staff Touch Faces While Feeding Residents - CO
The September inspection at Oakwood Care and Rehabilitation found staff routinely violated basic infection control during meals, with nurses and aides moving between residents without hand hygiene and handling drinking glasses by the rim before serving them to patients.
During breakfast on September 8, LPN #1 fed two unidentified dependent residents by alternating bites between them. She scratched her face and adjusted her face mask several times while moving from one resident to the other.
She never performed hand hygiene.
At 8:07 a.m., the regional dietary consultant walked over and delivered a bottle of hand sanitizer directly to the nurse's table, telling her to clean her hands after adjusting her mask. One minute later, the nurse finished feeding one resident and began assisting another.
She still didn't wash her hands.
Two days later, inspectors watched certified nurse aide #9 alternate feeding two dependent residents during lunch. The aide never performed hand hygiene between residents, and no hand sanitizer was visible at the dining room table.
The facility's own policy, revised in March 2021, requires staff to wash hands if they "have touched their face/hair, have touched a resident or wheelchair" before "passing additional trays." The director of nursing, who also serves as the infection preventionist, told inspectors that staff should perform hand hygiene between feeding different residents.
But the breakfast violations extended beyond unwashed hands.
CNA #10 carried four glasses of orange juice through the dining room with the glasses stacked on top of each other, so the rims of two glasses touched the bottoms of the other two. The aide held the stacked glasses in the middle, with her hand touching two glasses by the rim.
Minutes later, the same aide delivered two more glasses of orange juice, holding one glass by the rim. At 7:46 a.m., she delivered coffee to a resident while gripping the mug by its rim.
The director of nursing acknowledged staff should hold drinking glasses by the bottom, not the rim, when serving drinks to residents.
The Centers for Disease Control recommends healthcare workers clean hands immediately before touching a patient and after touching a patient or the patient's surroundings. Hand hygiene, according to CDC guidance, "protects both healthcare personnel and patients" and "reduces the potential spread of germs, including those resistant to antibiotics."
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting few residents. But the September 11 inspection revealed systematic failures in basic infection control during one of the facility's most routine daily activities.
The nurse who required prompting from the dietary consultant to use hand sanitizer was responsible for feeding dependent residents who relied entirely on staff assistance for nutrition. These residents had no ability to refuse contaminated utensils or request that staff wash their hands.
The aide who handled multiple drinking glasses by their rims was delivering beverages that residents would put directly to their lips. Orange juice glasses stacked rim-to-bottom created direct contamination pathways between different residents' drinks.
Oakwood Care's infection control failures occurred during a complaint inspection, suggesting the problems may have prompted outside concerns about the facility's sanitary practices. The 76-minute breakfast observation captured multiple staff members violating hand hygiene protocols across different types of resident assistance.
No hand sanitizer was available at dining room tables where aides fed residents, despite facility policy requiring hand hygiene between resident contact. Staff had to be reminded by supervisors to perform basic infection control measures they should have known automatically.
The inspection found the facility "failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease."
For dependent residents who cannot feed themselves, contaminated hands and drinking vessels represent direct exposure to whatever pathogens staff members carry from other residents, their own bodies, or environmental surfaces. The breakfast meal became a potential disease transmission event repeated three times daily.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Care and Rehabilitation from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO was cited for violations during a health inspection on September 11, 2025.
During breakfast on September 8, LPN #1 fed two unidentified dependent residents by alternating bites between them.
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.