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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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)
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
Potential for harm · D September 11, 2025
Provide activities to meet all resident's needs.
Corrected October 10, 2025 · Quality of Life and Care
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
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.