Oakwood Care And Rehabilitation

assisting residents with showering and transfer assistance to ensure her understanding of safe

previous knee injury, generalized weakness and a history of falling.

The 1/9/26 MDS assessment

resident required assistance from one to two staff members for transfers and bathing.2.

Resident interview Resident #23 was interviewed on 2/25/26 at 2:40 p.m. Resident #23 said she had a bad experience in the facility when CNA #3 provided her with rough care on more than one occasion, so she filed a complaint. Resident #23 said CNA #3 was assisting her to take a shower but CNA #3 pushed her onto the bath chair, threw the wash cloth on her and told her to wash herself. Resident #23 said CNA #3 was mean to her another time and told her to put herself to bed. Resident #23 was near tears and became upset, speaking loudly with a reddened face, when recalling these events and repeating that she did not want to work with CNA #3 again.Resident #23 said no other staff members were around to observe the incidents with CNA #3 and so she stood up for herself and filed complaints about CNA #3's treatment towards her. Resident #23 said reiterated that never wanted CNA #3 to help her again.3.

Record review Resident #23's behavior care plan, initiated 9/11/25, revealed Resident #23 had a potential for a behavior problem related to persistent depression disorder, anxiety and insomnia.Interventions included encouraging the resident to verbalize feelings related to her emotional state, monitoring behavior episodes and attempting to determine underlying cause, considering location, time of day, persons involved, and situations and documenting behavior and potential causes.-The behavior care plan revealed the resident required two staff members with bathing. III.

Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 1/26/26 at 4:45 p.m.

The DON said CNA #3 denied the allegations made by Resident #23.

The DON said Resident #23 was now being provided with care in pairs (more than one staff member) since the resident made the allegation of abuse against CNA #3, in order to protect the resident and the staff.

The DON and the NHA said facility staff were provided training on how to work with residents with limited cognitive and physical functioning.

The DON said Resident #23 had a history of depression and stroke and it was difficult to get detailed information from her during the investigation of the allegation.

The DON said they did not do any additional investigating of the allegation, other than what was documented in the facility investigation provided during the survey.

The DON said only one other resident complained about CNA #3 as a care giver ( on 2/12/26).

She said the facility changed that resident's caregiver assignment so CNA #3 no longer worked with her and that was the end of the resident's concerns.

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

every two hours at a minimum.CNA #8 was interviewed on 2/25/26 at 9:55 a.m. CNA #8 said

interviewed on 2/25/26 at 10:00 a.m. LPN #3 said dependent residents needed to be checked on for

director of nursing (DON) were interviewed together on 2/26/26 at 4:46 p.m.

The NHA and the DON said the expectation was that staff would check on dependent residents for incontinence and change them, if needed, every two hours.

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

observed to be consistently in place on Resident #17's door (see observations above).Licensed

dementia unit was the younger residents bothering the older residents. He said that all of the

prevent the residents from wandering unless they saw a resident go into another resident's room that was not theirs and then staff would redirect the resident out of the other residents' rooms as a preventative manner.-However, staff were not observed to be consistently redirecting residents out of other residents' rooms (see observations above).LPN #1 said that activities were good for the residents and the programs were improving as well.CNA #4 was interviewed on 2/25/26 at 1:30 p.m.

CNA #4 said a lot of residents, if not all residents, had wandering behaviors and wandered into other residents' rooms.

Cross -reference F-F600 for failure to keep residents free from abuse.CNA #4 said that he had made the recommendation of having a red stripe barrier placed on all the residents' rooms to prevent wandering. He said the activities programming in the secure memory care unit was getting better. He said when a resident did not participate in activities, he would try and get them reengaged with that activity.LPN #2 was interviewed at 10:35 a.m on 2/26/26. LPN #2 said Resident #24 wandered the most out of all the residents. He said unfortunately they could not stop residents from going into other residents' rooms. He said they could try to redirect the residents from wandering into other residents' rooms but it was difficult LPN #2 said the energy in the secure memory care unit changed quickly and it was difficult to manage sometimes. He said activities programming was important to keep the residents occupied and engaged. He said he would like to see more one-to-one activities with residents but he said he knew that this was difficult, based on staffing and the need for the staff to attend to the residents' care needs. LPN #2 said training on resident care plans and interventions was provided and when provided for the residents, the care planned interventions made the day-to-day activities in the unit run more smoothly.CNA #10 was interviewed on 2/26/26 at 1:20 p.m. CNA #10 said when resident-to-resident altercations occurred, he would separate the residents and redirect the residents away from each other. CNA #10 said it was most beneficial to prevent residents from going into another resident's room initially. He said he did this by telling the resident not to go into another person's room. He said he did not know where the residents' care plans were, but knew that they were somewhere in the office.

The nursing home administrator (NHA) was interviewed on 2/26/26 at 4:46 p.m.

The NHA said the facility was working hard to prevent resident-to-resident altercations and abusive behaviors between residents.

She said the facility's leadership team had implemented training for staff to learn redirection techniques for residents.

She said leadership was working on contracting with a specialist in dementia-managed care to assist staff with providing improved care and services for residents diagnosed with dementia.

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The facility failed to protect residents from abuse on several occasions when residents were able to wander from room to room in the secure memory unit, resulting in resident-to-resident physical abuse. B.

Cross-reference F-F744:

The facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment to attain or maintain their highest level of care. III.

Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 2/25/26 at 10:25 a.m The DON and the NHA said the facility did not have a QAPI PIP plan in place for the secure memory care unit at this time, but did talk about plans for the unit such as the ability cares programming.

The NHA and the DON were interviewed together again on 2/26/26 at 4:46 p.m.

The NHA and the DON said the facility was working hard to prevent residents' abusive behaviors and to train the staff on crisis prevention intervention (CPI) and dementia care procedures.

The DON said that staff needed education related to abuse and dementia and they had not had that.The DON said the facility was working on several PIPs at that time, including falls and dementia training but could not provide specific details about the specific PIPS.

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report abuse, neglect, and exploitation.

minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation

misappropriation of resident property and resident abuse prevention.Specifically, the facility failed to ensure contracted and agency staff met training requirements, including timely reporting of suspected abuse.

Findings include:I.

Facility policy and procedureThe Abuse policy, revised April 2025, was provided by the regional nurse consultant on 2/23/26 at 12:00 p.m.

The policy read in pertinent part, The facility will provide oversight and monitoring to ensure its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy.

This policy applies to all facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the facility. II.

Record review and staff interview An allegation of neglect incident report, dated 11/25/25, documented the allegation was initiated by a hospice certified nurse aide (CNA) who believed a resident being provided care by himself and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period of time.

The incident report and facility investigation revealed the contracted hospice CNA failed to report suspected neglect in a timely manner.

The incident report documented that although the hospice CNA witnessed suspected neglect on 11/9/25, the allegation was not reported to the facility until 11/19/25, ten days later. A request was made to the regional nurse consultant on 2/24/26 at 12:00 p.m. for documentation of training provided to contracted and agency staff working with the facility's residents, in relation to the facility's policies and procedures and expectations for reporting abuse.

The regional nurse consultant provided training records of abuse identification, prevention and reporting for facility staff, however, she was unable to provide any facility-specific abuse training that had been provided to contracted or agency staff.

The regional nurse said the contracted and agency staff members were trained on abuse by their agency, prior to coming to work at the facility.III.

Staff interviewsCNA #6 was interviewed on 2/24/26 at 4:25 p.m.

CNA #6 said she was an agency employee.

She said the facility had not provided any supplementary training regarding facility policies and facility expectations related to abuse and neglect prior to her starting her shifts at the facility.

The regional nurse consultant was interviewed on 2/25/26 at 4:23 p.m The regional nurse consultant said she thought the agency's and other contracted staff were educated on abuse by their agency and the facility did not need to provide additional training to the contracted and agency staff related to abuse and abuse reporting.

The regional nurse consultant agreed it would be beneficial for the facility to provide a read and sign binder for agency and contracted staff so they were aware of relevant facility policies and expectations for reporting abuse.

The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 2/4/26 at 4:46 p.m.

The DON said she thought the facility needed to work better with their hospice agency so the hospice agency had certain points of contact to keep in touch with facility leadership when concerns occurred.

The DON said the facility had not provided training to agency staff in relation to reporting abuse, but they were planning to develop educational binders that could be used for agency staff training.