Map showing the location of OAKWOOD CARE AND REHABILITATION in LAKEWOOD, Colorado
5301 W 1ST AVE, LAKEWOOD, CO, 80226

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • ColoradoLowest tier among peers208 rated homes · average 3.1★
  • Jefferson CountyLowest tier among peers23 rated homes · average 3.0★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.7 vs CO avg
  • StaffingCan add or remove a star3★−0.1 vs CO avg
  • Quality measuresCan add or remove a star3★−1.2 vs CO avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCO avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersCO avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 7% of peersCO avg4.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.12hrsAbove only 21% of peersCO avg3.73Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.60hrsAbove only 27% of peersCO avg0.83Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better48%Above 52% of peersCO avg49%RN turnover31%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$235,923Lowest tier among peersCO avg$25,587Fines · denials4 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
69citations
9inspection dates
9actual harm (G–I)
2immediate jeopardy (J–L)
Dec 18, 2025most recent

Citations by monthNov 2022 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 18, 20254 citationsCycle 1worst E · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jan 15, 2026
  2. F584Honor 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.Resident RightsE · patternCorrected Dec 23, 2025
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 15, 2026
  4. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Dec 31, 2025
Sep 11, 20256 citationsCycle 1worst F · no actual harm
  1. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Oct 10, 2025
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Oct 10, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 10, 2025
  4. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 10, 2025
  5. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Oct 10, 2025
  6. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Oct 10, 2025
Jun 12, 20253 citationsCycle 1worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jul 4, 2025
  2. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Jul 4, 2025
  3. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 4, 2025
Jan 29, 20256 citationsCycle 2worst G · actual harm$53,151, payment denial
  1. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Mar 7, 2025
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 7, 2025
  3. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 7, 2025
  4. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 7, 2025
  5. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 7, 2025
  6. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Mar 7, 2025
Apr 10, 202416 citationsCycle 2worst G · actual harm$52,416
  1. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 2, 2024
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 5, 2024
  3. F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareE · patternCorrected May 5, 2024
  4. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected May 2, 2024
  5. F758Implement 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.Pharmacy ServiceD · isolatedCorrected May 5, 2024
  6. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 5, 2024
  7. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected May 5, 2024
  8. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected May 2, 2024
  9. F584Honor 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.Resident RightsD · isolatedCorrected May 5, 2024
  10. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected May 5, 2024
  11. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 5, 2024
  12. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 5, 2024
  13. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareE · patternCorrected May 5, 2024
  14. F791Provide or obtain dental services for each resident.Quality of Life and CareE · patternCorrected May 5, 2024
  15. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 2, 2024
  16. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected May 2, 2024
Oct 9, 202313 citationsCycle 3worst K · immediate jeopardy$111,704, payment denial
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsG · isolatedCorrected Nov 9, 2023
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Nov 24, 2023
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Nov 9, 2023
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 28, 2023
  5. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 9, 2023
  6. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareG · isolatedCorrected Nov 9, 2023
  7. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Nov 9, 2023
  8. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareG · isolatedCorrected Nov 9, 2023
  9. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareG · isolatedCorrected Nov 9, 2023
  10. F838Conduct 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.AdministrationF · widespreadCorrected Nov 9, 2023
  11. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Nov 9, 2023
  12. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Nov 9, 2023
  13. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsC · widespreadCorrected Nov 9, 2023
Jul 20, 20232 citationsCycle 3worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Aug 11, 2023
  2. F814Dispose of garbage and refuse properly.Nutrition and DietaryF · widespreadCorrected Aug 11, 2023
May 4, 20231 citationCycle 3worst J · immediate jeopardy$18,652
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jun 2, 2023
Nov 17, 202218 citationsCycle 3worst G · actual harm
  1. F761Ensure 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.Pharmacy ServiceE · patternCorrected Dec 17, 2022
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 17, 2022
  3. F803Ensure 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.Nutrition and DietaryD · isolatedCorrected Dec 17, 2022
  4. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Dec 17, 2022
  5. F567Honor the resident's right to manage his or her financial affairs.Resident RightsD · isolatedCorrected Dec 17, 2022
  6. F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsD · isolatedCorrected Dec 17, 2022
  7. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Dec 17, 2022
  8. F584Honor 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.Resident RightsE · patternCorrected Dec 17, 2022
  9. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 17, 2022
  10. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Dec 17, 2022
  11. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Dec 17, 2022
  12. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Dec 17, 2022
  13. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Dec 17, 2022
  14. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Dec 17, 2022
  15. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Dec 23, 2022
  16. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Dec 22, 2022
  17. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Dec 17, 2022
  18. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Dec 17, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.12hrsAbove only 21% of peers−0.61 vs CO avg
  • Registered nursesRN hours only0.60hrsAbove only 27% of peers−0.23 vs CO avg
  • Licensed practical nursesLPN hours0.58hrs
  • Nurse aidesCNA hours1.95hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.85hrs
  • Colorado average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better48%Above 52% of peersCO avg 49%
  • RN turnoverRegistered nurses only31%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy170 certified beds · ~108 residents a day64%Above only 18% of peersCO avg 79%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $235,923In fines
  • 4Fines
  • 2Payment denials
  • $25,587CO avg in fines
Lowest tier among peersMore in fines than nearly every rated home in Colorado

Actions on record

  1. Jan 29, 2025Civil money penalty$53,151
  2. Jan 29, 2025Denial of payment for new admissionsfrom Feb 27, 2025
  3. Apr 10, 2024Civil money penalty$52,416
  4. Oct 9, 2023Civil money penalty$111,704
  5. Oct 9, 2023Denial of payment for new admissionsfrom Nov 7, 2023
  6. May 4, 2023Civil money penalty$18,652

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Endura Healthcare LLC
Indirect owners (5%+)
  • The Ensign Group INC
Operational or managerial control
  • Kare Technologies LLC
  • Onshift INC
  • Sos Nursing Services, INC
  • Eddy Boyles
  • Gregory Gahm
Corporate directors
  • David Jorgensen
Corporate officers
  • Soon Burnam
  • David Dunyon
  • Chad Keetch
  • Ami Sato

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 065248 · 5301 W 1ST AVE, LAKEWOOD, CO, 80226.
  • Percentiles compare this facility with every rated nursing home in Colorado and Jefferson County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

Own or manage a facility?

Claim your free listing to correct details, reply to reviews, and show your verified badge.

Claim your facility

Read our latest articles