Federal inspection record · CMS data as of October 1, 2026
Oakwood Care And Rehabilitation
5301 W 1st Ave, Lakewood, CO · (303) 238-8333
- Cited for abuse (CMS abuse icon)
- Certified beds
- 170
- Residents per day
- 134
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- March 1, 1989
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Colorado homes
Oakwood Care And Rehabilitation carries 189.25 inspection points. That is fewer than 2% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
72 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (10)
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
-
G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
-
G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
-
G
Provide medically-related social services to help each resident achieve the highest possible quality of life.
-
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care16E
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide activities to meet all resident's needs.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- E
Assist a resident in gaining access to vision and hearing services.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- E
Provide or obtain dental services for each resident.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Resident Rights13E
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- D
Honor the resident's right to manage his or her financial affairs.
- D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
- D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Freedom from Abuse, Neglect, and Exploitation8E
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- E
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Nutrition and Dietary5F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Pharmacy Service5E
- D
Ensure that residents are free from significant medication errors.
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Administration4F
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
- F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- E
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Resident Assessment and Care Planning3D
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Nursing and Physician Services3E
- D
Observe each nurse aide's job performance and give regular training.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- E
Observe each nurse aide's job performance and give regular training.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspection history
2025-09-11
16 health deficiencies · 14 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-04-10
24 health deficiencies · 12 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2022-11-17
32 health deficiencies · 20 fire-safety deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 47 min of nursing staff time a day, 26 min of it from a registered nurse.
This home
2 h 47 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 60% of nursing staff and 70% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$105,567 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-01-29 | Fine | $53,151 |
| 2025-01-29 | Payment Denial · 8 day denial | $0 |
| 2024-04-10 | Fine | $52,416 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.1 pts worse | 1.5 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.8 pts better | 0.9 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine2.6 pts better | 96.0% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine6.7 pts worse | 87.0% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.3 pts better | 3.1% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms10.6 pts worse | 19.4% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts worse | 6.6% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication4.5 pts better | 7.1% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3.2 pts worse | 23.1% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.5 pts worse | 13.2% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased9 pts worse | 21.8% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.6 pts worse | 1.1% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.5 pts better | 0.9% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.6 pts worse | 29.2% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.5 pts worse | 3.9% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine10.7 pts worse | 66.3% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit9.2 pts better | 2.8% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication5.8 pts worse | 7.4% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine13.1 pts worse | 60.5% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission13.7 pts worse | 34.2% | 20.5% | 23.4% |
·
Who owns and runs it
20 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Boyles, Eddy | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Boyles, Eddy | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Boyles, Eddy | Adp Of The SNF · Individual | 0% | 2 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Burnam, Soon | Adp Of The SNF · Individual | 0% | 353 facilities |
| Caretrust Gp LLC | Adp Of The SNF · Organization | 0% | 95 facilities |
| Caretrust Reit Inc | Adp Of The SNF · Organization | 0% | 102 facilities |
| Ctr Partnership LP | Adp Of The SNF · Organization | 0% | 104 facilities |
| Dunyon, David | Corporate Officer · Individual | 0% | 12 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Gahm, Gregory | Managing Control - Governing Body · Individual | 0% | 5 facilities |
| Gahm, Gregory | Operational/Managerial Control · Individual | 0% | 5 facilities |
| Gahm, Gregory | Adp Of The SNF · Individual | 0% | 5 facilities |
| Jorgensen, David | Corporate Director · Individual | 0% | 56 facilities |
| Kare Technologies LLC | Operational/Managerial Control · Organization | 0% | 10 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Onshift Inc | Operational/Managerial Control · Organization | 0% | 20 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Sato, Ami | Corporate Officer · Individual | 0% | 151 facilities |
| Sos Nursing Services, Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
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Fire safety
46 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke18F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Provide properly protected cooking facilities.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Provide properly protected cooking facilities.
- E
Install a fire alarm system that can be heard throughout the facility.
- E
Install properly constructed windows in hallway walls or doors.
- E
Have properly sized and located compartments to protect residents from smoke.
Egress10F
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
Provide at least two remote exits on each floor or fire section of the building.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- D
Provide large enough exits.
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F
Have exits that are accessible at all times.
- F
Install emergency lighting that can last at least 1 1/2 hours.
- F
Have properly located and lighted "Exit" signs.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have proper medical gas storage and administration areas.
Emergency Preparedness5F
- F
Establish an Emergency Preparedness Program (EP).
- F
Develop Emergency Preparedness policies and procedures.
- F
Develop a communication plan.
- F
Establish emergency prep training and testing.
- F
Develop and maintain an Emergency Preparedness Program (EP).
Services4F
- F
Install properly constructed and protected linen or trash chutes.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Install properly constructed and protected linen or trash chutes.
Miscellaneous3F
- F
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
Construction1F
- F
Use approved construction type or materials.
·
Other homes nearby
-
Mapleton Post Acute
Lakewood, CO · The Ensign Group
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 2 h 53 min
- Fines
- $0
-
Sierra Post Acute
Lakewood, CO · Pacs Group · Abuse icon
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 36 min
- Fines
- $54,903
-
Cedars Healthcare Center
Lakewood, CO · Stellar Senior Living
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 3 min
- Fines
- $15,759