Skip to main content
Complaint Investigation

Oakwood Care And Rehabilitation

January 29, 2025 · Lakewood, CO · 5301 W 1st Ave
Citations 3
CMS Rating 1/5
Beds 170
Provider ID 065248
Healthcare Facility
Oakwood Care And Rehabilitation
Lakewood, CO  ·  View full profile →
Inspection Summary

OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO — inspection on January 29, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF600
Minimal harm or difficult to determine which behaviors might be directed at staff and which behaviors might be directed at Few affected

During a continuous observation of unit four on 1/27/25, beginning at 11:17 a.m. and ending at 2:00 p.m., the following was observed:

At 11:17 a.m. the droplet precaution sign had been removed from Resident #12's door and the PPE bin was no longer outside the resident's room.

-There was no EBP sign on Resident #12's door or a PPE bin outside the resident's room, was identified by the director of nursing (DON) as the facility's process for making staff aware of which residents required EBP (see DON interview below).

At 1:09 p.m. the physical therapist (PT) was observed going into Resident #12's room and asking the resident if he was ready for some exercise.The PT performed hand hygiene and closed the resident's door.

-The PT did not put on PPE prior to entering the resident's room to do physical therapy with the resident.

At 1:42 p.m. the speech language pathologist (SLP) performed hand hygiene, knocked on Resident #12's door and entered the resident's room.

-The SLP did not put on PPE prior to entering the resident's room to do speech therapy with the resident.

065248

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065248 B.

Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Care and Rehabilitation 5301 W 1st Ave Lakewood, CO 80226

According to the January 2025 CPO, diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, chronic respiratory failure, emphysema, depressive episodes, cognitive communication deficit and the need for assistance with personal care.

The 1/1/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of two out of 15. Resident #8 required substantial to maximal assistance with toileting hygiene, bathing and lower body dressing, moderate assistance with personal hygiene and transfers, and supervision with eating.

The MDS assessment documented Resident #8 had physical and behavioral symptoms directed toward others.

2.

Record review

Resident #8's behavior care plan, revised 4/3/24, documented the resident had potential to become verbally and physically aggressive toward others related to dementia and Alzheimer's disease.

The care plan indicated his triggers were not understanding his surroundings and others approaching him from behind or not in his line of vision.

Pertinent interventions, initiated 3/14/24, included if the resident could not be redirected or calmed, and if safe to do so, staff were to attempt to perform cares at a later time after the resident was calm, offering a deck of cards and staff to approach the resident within his line of vision.

Interventions added on 11/11/24 included to approach the resident from the front or make it known you were approaching, redirect the resident and/or offering the resident a deck of cards.

D. Resident #1 (victim)

1.

Resident status

065248

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065248 B.

Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Care and Rehabilitation 5301 W 1st Ave Lakewood, CO 80226

F-F744 for failure to provide a person centered dementia services.

On 7/18/24 a nursing progress note, written at 3:55 p.m., documented Resident #2 approached multiple residents screaming and cursing at them for no reason.

The staff directed Resident #2 away from the other residents and offered Resident #2 food and conversation.

The assistant director of nursing (ADON) and on-call provider were notified.

Cross reference

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAKEWOOD, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAKWOOD CARE AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement