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Complaint Investigation

Oakwood Care And Rehabilitation

September 11, 2025 · Lakewood, CO · 5301 W 1st Ave
Citations 6
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 September 11, 2025.

Found 6 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.

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Inspection Findings

FF0677
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of OAKWOOD CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-10.

Federal health inspectors cited OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-09-11.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide activities to meet all resident's needs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of OAKWOOD CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-10.

Federal health inspectors cited OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO for a deficiency under regulatory tag F-F0730 during a standard health inspection conducted on 2025-09-11.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of OAKWOOD CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-10.

contact with ready-to-eat foods.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/11/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakwood Care and Rehabilitation

5301 W 1st Ave Lakewood, CO 80226

SUMMARY STATEMENT OF DEFICIENCIES

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Based on observations, record review, and interviews, 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.Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene assisting residents with eating; and,-Ensure staff handled residents' drinkware in a sanitary manner.Findings include:I.

Failed to ensure staff performed hand hygiene while assisting residents with eatingA.

Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 9/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients.

Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics.

Clean your hands immediately before touching a patient and after touching a patient or the patient's surroundings.B.

Facility policy and procedureThe Dining and Infection Control policy, revised March 2021, was received from the NHA on 9/11/25 at 11:15 a.m. It read in pertinent part, Staff will perform appropriate hand hygiene. If hands are soiled, have touched their face/hair, have touched a resident or wheelchair, they will wash their hands before passing additional trays.C.

ObservationsDuring a continuous observation of the breakfast meal in the main dining room on 9/8/25, beginning at 7:10 a.m. and ending at 8:26 a.m., the following was observed:At 8:05 a.m. licensed practical nurse (LPN) #1 was assisting two unidentified dependent residents with eating. LPN #1 alternated offering each resident a bite of food before offering a bite of food to the other resident. LPN #1 scratched her face and adjusted her face mask several times while alternating between offering bites of food to each resident.-LPN #1 did not perform hand hygiene after touching her face or mask and between offering bites of food to each resident.At 8:07 a.m. the regional dietary consultant delivered a bottle of hand sanitizer to the table where LPN #1 was sitting and told her to perform hand hygiene after adjusting her mask.At 8:08 a.m. LPN #1 finished assisting one of the unidentified residents with eating and began assisting another unidentified resident. -LPN #1 did not perform hand hygiene before assisting the other resident with eating.On 9/10/25 at 12:39 p.m. certified nurse aide (CNA) #9 was sitting in the dining room at a table assisting two unidentified dependent residents with eating. CNA #9 was alternating offering each resident a bite of food.-CNA #9 did not perform hand hygiene between assisting the two residents. -Additionally, there was no hand sanitizer visibly available at the dining room table.D.

Staff interviewThe director of nursing (DON), who was also the facility's infection preventionist (IP), was interviewed on 9/11/25 at 12:40 p.m.

The DON said the staff should perform hand hygiene in between feeding different residents.II.

Failed to handle residents' drinkware in a sanitary mannerA.

ObservationsDuring a continuous observation of the breakfast meal in the main dining room on 9/8/25, beginning at 7:10 a.m. and ending at 8:26 a.m., the following was observed:At 7:42 a.m. CNA #10 carried four glasses of orange juice through the dining room to deliver to residents. CNA #10 had the glasses stacked one on top of the other so the rims of two of the glasses were touching the bottom of the other two glasses. CNA #10 was holding the stacked glasses in the middle of the stack and her hand was touching two of the glasses by the rim of the glass. At 7:45 a.m. CNA #10 delivered two more glasses of orange juice to residents in the dining room. CNA #10 held one of the glasses by the rim of the glass. At 7:46 a.m. CNA #10 delivered a mug of coffee to a resident in the dining room. CNA #10 held the coffee mug by the rim of the mug.B.

Staff interviewThe DON was interviewed on 9/11/25 at 12:40 p.m.

The DON said the staff should hold residents' drinking glasses by the bottom of the glass.

The DON said the staff should not hold the rim of the glass when serving drinks to residents.

Facility ID:

Federal health inspectors cited OAKWOOD CARE AND REHABILITATION in LAKEWOOD, CO for a deficiency under regulatory tag F-F0947 during a standard health inspection conducted on 2025-09-11.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of OAKWOOD CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-10.

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.


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