Oakwood Care and Rehabilitation
5301 W 1st Ave · Lakewood, CO · 80226 · 3032388333
170 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $53,151 in fines in the last 24 months.
- 9 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$53,151 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.90 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 2.90 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.53 | 0.55–0.75 |
| Weekend hours / resident-day | 2.67 | ≈ weekday level |
| Nursing turnover / year | 51% | median 45% |
| Fines (3-yr window) | 3 · $217,271 |
Inspection citations (74 in the current record)
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Potential for harm · E February 26, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 23, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 26, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected March 23, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 26, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · E February 26, 2026 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · F February 26, 2026 · found via complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected March 23, 2026 · Administration
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Potential for harm · E February 26, 2026 · found via complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected March 23, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 18, 2025 · found via complaint
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected December 31, 2025 · Resident Rights
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Potential for harm · D December 18, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected January 15, 2026 · Resident Rights
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Potential for harm · E December 18, 2025 · found via complaint
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.
Corrected December 23, 2025 · Resident Rights
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Potential for harm · D December 18, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 15, 2026 · Resident Assessment and Care Planning
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Potential for harm · D September 11, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 10, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Provide activities to meet all resident's needs.
Corrected October 10, 2025 · Quality of Life and Care
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Potential for harm · D September 11, 2025
Observe each nurse aide's job performance and give regular training.
Corrected October 10, 2025 · Nursing and Physician Services
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Potential for harm · D September 11, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected October 10, 2025 · Nursing and Physician Services
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Potential for harm · F September 11, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 10, 2025 · Nutrition and Dietary
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Potential for harm · D September 11, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected October 10, 2025 · Infection Control
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Potential for harm · E June 12, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 4, 2025 · Resident Rights
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Potential for harm · D June 12, 2025 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected July 4, 2025 · Resident Rights
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Potential for harm · D June 12, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected July 4, 2025 · Pharmacy Service
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Actual harm · G January 29, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 29, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 29, 2025 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected March 7, 2025 · Quality of Life and Care
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Potential for harm · E January 29, 2025 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected March 7, 2025 · Nutrition and Dietary
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Potential for harm · E January 29, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 7, 2025 · Nutrition and Dietary
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Potential for harm · D January 29, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 7, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 29, 2025 | Fine | $53,151 |
| January 29, 2025 | Payment Denial | 8 days |
| April 10, 2024 | Fine | $52,416 |
| October 9, 2023 | Fine | $111,704 |
| October 9, 2023 | Payment Denial | 21 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065248 · certified since March 1, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.