Oakwood Care And Rehabilitation

could better anticipate a resident's needs and recognize if a resident's behavior began to change and

065248 01/29/2025

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

they were sporadic and it was difficult to identify a trend in his behaviors.

reviewing the documentation in Resident #2's record the facility recognized the documentation errors

the facility implemented a plan to only schedule facility staff in the secured unit where Resident #2 resided The RCR said facility staff knew the residents better, could better anticipate a resident's needs and recognize if a resident's behavior began to change and intervene before the behavior escalated.

065248 01/29/2025

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

partially uncovered leaving the food exposed.

four surveyors after the last resident had been served their room tray for lunch.

The test tray consisted of a breaded chicken breast, penne pasta with marinara sauce, broccoli and cake for dessert. -The broccoli was 102 degrees F. -The chicken breast was 120 degrees F -The penne pasta was 102 degrees F The cake did not have icing and the pasta was overcooked and soggy.

IV.

Staff interviews The dietitian resource (DR) was interviewed on 1/29/25 at 1:00 p.m.

The DR said the plates used for the 400 hall room trays, including the test tray, were not placed in the plate warmer prior to meal assembly.

The DR said plates placed in the plate warmer were used for room trays and the plates left on the shelf at room temperature were usually used for the dining room.

The DR said the facility did purchase another case of plates (during the survey) so this would not happen again and ensured the plate warmer always had hot plates for room tray service.

The DR said she spoke with the dietary staff after meal service and the staff reported to her they do not typically run out of plate covers and lids.

The DR said it was possible that not all plate covers and lids were returned to the kitchen after breakfast that morning.

The DR said they should have enough plate covers and lids for lunch in case the meal trays are not all returned after breakfast.

The DR said she updated the facility dietary improvement plan initiated in October 2024 to include food temperatures.

V.

Facility follow up The dietary improvement plan, October 2024 was provided by the DR on 1/29/25 p.m. at 2:00 p.m.

The plan was updated to include the following correction action items of food temperatures: purchase more plates, to ensure all food items were covered and to utilize two steam tables for meal service. -However, additional plates were not purchased until the survey (1/27/25 to 1/29/25).

065248 01/29/2025

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

Licensed practical nurse (LPN) #2 was interviewed on 1/28/25 at 11:07 a.m. LPN #2 said the jar of green chile (see above) belonged to the resident whose name was on the jar. LPN #2 said she would discard the jar of green chile because it did not have a date written on it, but the printed date on the jar was in 2026. -LPN #2 discarded the jar of green chile.

The dietitian resource (DR) was interviewed on 1/29/25 at 1:00 p.m.

The DR said it was the responsibility of all the dietary staff to pay attention to the food labels.

The DR said the staff should write a pull date on the item when it was removed from the freezer.

The DR said typically the label should be put on the tray or container instead of the product itself because the label did not adhere well to the product packaging.

The DR said the dietary staff had previously been instructed how to date and label.

The DR said cleaning unit refrigerators were on the dietary staff checklist to be completed every week.

The DR said the nourishment refrigerators were managed by dietary staff.

The DR said if a family member brought in personal food items for a resident, then the staff member who received that food, such as a CNA, was responsible for dating and labeling the food prior to putting the food in the nourishment refrigerators.

The director of nursing (DON) was interviewed on 1/29/25 at 1:00 p.m.

The DON said medications were not typically stored in the nourishment refrigerators and were removed from the nourishment refrigerator.

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

the droplet precautions sign and PPE bin from Resident #12's door on 1/27/25 because the resident

would be more vigilant about ensuring the EBP measures were maintained in the future.

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