Nursing homeFAID #1338
Oakwood Care and Rehabilitation
★★★★★1/5CMS Five-Star overall1/5 health inspections3/5 staffing4/5 quality measuresSource: CMS Care Compare
Photo via Google · Danna Roberts
Public record summary
What we can show you for free.
Bed capacity
170
State license
020420
CMS facility ID
065248
Care type
Nursing home
Facility name
Oakwood Care and Rehabilitation
Street address
5301 W 1ST AVE
City / state / ZIP
Lakewood, CO 80226
Phone
(303) 238-8333
Website
State license #
020420
About this facility — Oakwood Care and Rehabilitation
Oakwood Care and Rehabilitation is a Medicare/Medicaid-certified skilled nursing facility in Lakewood, Colorado. It is licensed for 170 beds — well above the median for skilled nursing facilities in Colorado (90 beds).
It is one of 68 senior care facilities in Lakewood and 210 skilled nursing facilities across Colorado. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.
Federal inspectors have cited Oakwood Care and Rehabilitation 118 times across 13 inspections in the last three years, including 5 food-safety citations, and CMS has imposed $217,271 in fines. Every citation is listed, dated, and graded in the inspection record below.
This listing draws on federal CMS Nursing Home Compare records, and was last updated on August 31, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.
Facility background
What the public record shows.
Ownership & operator
Parent company
The Ensign Group
Ownership type
For profit - Corporation
Registered owners & officers
Boyles, Eddy
Governing body · Operational control · Additional disclosable party — since 2023
Burnam, Soon
Officer · Additional disclosable party — since 2023
Caretrust Gp Llc
Additional disclosable party — since 2024
Caretrust Reit Inc
Additional disclosable party — since 2024
Ctr Partnership Lp
Additional disclosable party — since 2024
Dunyon, David
Officer — since 2024
Ensign Services Inc
Additional disclosable party — since 2023
Gahm, Gregory
Governing body · Operational control · Additional disclosable party — since 2024
Jorgensen, David
Director — since 2024
Kare Technologies Llc
Operational control — since 2024
Keetch, Chad
Officer — since 2011
Onshift Inc
Operational control — since 2024
Port, Barry
Owner of a disclosable party — since 2025
Sato, Ami
Officer — since 2024
Sos Nursing Services, Inc
Operational control — since 2024
Regulatory standing
Federal court records
11 naming its parent company — view the cases (a listed case is not a finding of wrongdoing)
License status
Active
Licensed / certified since
1989-03-01
CMS overall rating
1 of 5 stars
Health deficiencies
16 at the last standard inspection
Federal fines
$217,271 total
Last standard inspection
2025-09-11
Nurse staffing
3.0 hours per resident per day
Cost & payer profile (FY2023 cost report)
Average billed charges
$361 per day (≈ $10,970/month). Private-pay prices typically track billed charges; Medicare and Medicaid pay set rates.
Payer mix (resident days)
89% Medicaid · 2% Medicare · 9% private/other
Occupancy
65% (fiscal year 2023)
Vs. state median
11% below the CO median of $407/day — full state cost breakdown
Services & coverage
Licensed beds
170
Licensed as
Nursing Facilities
Medicare
Accepted
Medicaid
Accepted
Wheelchair accessible
entrance and parking
Compiled from CMS Nursing Home Compare; owners/officers from the CMS Ownership dataset; cost & occupancy from the facility's own CMS cost report; hours/accessibility via Google · last verified 2026-08-31. Facilities can submit a correction.
Inspection record
Every citation, dated and graded.
Kitchen & food safety
Federal surveyors inspect the kitchen at every standard visit. This facility has 5 food-safety citations on its three-year record — flagged below among the inspections.
2026-02-26Health inspectionComplaint-triggered6 citations
F-0600
E · No harm foundFrom a complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-03-23
F-0610
D · No harm foundFrom a complaint
Respond appropriately to all alleged violations.
Corrected 2026-03-23
F-0677
D · No harm foundFrom a complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-03-23
F-0744
E · No harm foundFrom a complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-03-23
F-0867
F · No harm foundFrom a complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2026-03-23
F-0943
E · No harm foundFrom a complaint
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2026-03-23
2025-12-18Health inspectionComplaint-triggered4 citations
F-0553
D · No harm foundFrom a complaint
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-12-31
F-0580
D · No harm foundFrom a complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-15
F-0584
E · No harm foundFrom a 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 2025-12-23
F-0658
D · No harm foundFrom a complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-15
9 earlier / fire-safety inspections (108 citations)
2025-09-11Health inspectionComplaint-triggered6 citations
F-0677
D · No harm found
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-10
F-0679
D · No harm found
Provide activities to meet all resident's needs.
Corrected 2025-10-10
F-0730
D · No harm found
Observe each nurse aide's job performance and give regular training.
Corrected 2025-10-10
F-0812
F · No harm foundFood safetyFrom a complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-10
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
F-0947
D · No harm found
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-10-10
2025-06-12Health inspectionComplaint-triggered3 citations
F-0550
E · No harm foundFrom a complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-04
F-0628
D · No harm foundFrom a complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-04
F-0760
D · No harm foundFrom a complaint
Ensure that residents are free from significant medication errors.
Corrected 2025-07-04
2025-01-29Health inspectionComplaint-triggered6 citations
F-0600
G · Actual harmFrom a complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-07
F-0609
D · No harm foundFrom a complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-07
F-0744
D · No harm foundFrom a complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-07
F-0804
E · No harm foundFood safetyFrom a complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-03-07
F-0812
E · No harm foundFood safetyFrom a complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-07
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
2024-04-10Health inspectionComplaint-triggered16 citations
F-0561
D · No harm foundFrom a complaint
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-02
F-0584
D · No harm foundFrom a 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 2024-05-05
F-0600
G · Actual harmFrom a complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-05
F-0610
D · No harm foundFrom a complaint
Respond appropriately to all alleged violations.
Corrected 2024-05-05
F-0677
D · No harm foundFrom a complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-05
F-0684
D · No harm found
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-05
F-0685
E · No harm found
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-05-05
F-0690
D · No harm found
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-02
F-0697
D · No harm foundFrom a complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-05
F-0744
E · No harm foundFrom a complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-05
F-0758
D · No harm found
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.
Corrected 2024-05-05
F-0761
D · No harm found
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.
Corrected 2024-05-02
F-0791
E · No harm foundFrom a complaint
Provide or obtain dental services for each resident.
Corrected 2024-05-05
F-0880
E · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2024-05-02
F-0883
E · No harm foundFrom a complaint
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-05-02
F-0921
E · No harm found
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-05
2023-10-09Health inspectionComplaint-triggered13 citations
F-0550
G · Actual harmFrom a complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-09
F-0577
C · No harm foundFrom a complaint
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-11-09
F-0600
K · Immediate jeopardyFrom a complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-24
F-0609
D · No harm foundFrom a complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-28
F-0610
D · No harm foundFrom a complaint
Respond appropriately to all alleged violations.
Corrected 2023-11-09
F-0684
G · Actual harmFrom a complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-09
F-0697
G · Actual harmFrom a complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-09
F-0730
E · No harm foundFrom a complaint
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-09
F-0744
G · Actual harmFrom a complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-11-09
F-0745
G · Actual harmFrom a complaint
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-11-09
F-0838
F · No harm foundFrom a complaint
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.
Corrected 2023-11-09
F-0842
D · No harm foundFrom a complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-09
F-0867
F · No harm foundFrom a complaint
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-09
2022-11-17Health inspection18 citations
F-0567
D · No harm found
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-12-17
F-0568
D · No harm found
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-12-17
F-0584
E · No harm found
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 2022-12-17
F-0600
E · No harm found
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-12-17
F-0622
D · No harm found
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.
Corrected 2022-12-17
F-0623
D · No harm found
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-12-17
F-0644
D · No harm found
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-12-17
F-0676
D · No harm found
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-12-17
F-0677
E · No harm found
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-17
F-0686
G · Actual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-23
F-0689
G · Actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-22
F-0690
D · No harm found
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-17
F-0695
E · No harm found
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-17
F-0757
D · No harm found
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-17
F-0761
E · No harm found
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.
Corrected 2022-12-17
F-0803
D · No harm foundFood safety
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.
Corrected 2022-12-17
F-0812
E · No harm foundFood safety
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-17
F-0849
D · No harm found
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.
Corrected 2022-12-17
2025-09-11Fire-safety inspection14 citations
K-0161
F · No harm found
Use approved construction type or materials.
K-0211
E · No harm found
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-31
K-0222
F · No harm found
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.
Corrected 2026-01-31
K-0252
E · No harm found
Provide at least two remote exits on each floor or fire section of the building.
K-0291
F · No harm found
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-01-31
K-0324
E · No harm found
Provide properly protected cooking facilities.
Corrected 2026-01-31
K-0345
F · No harm found
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-31
K-0353
E · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-31
K-0355
F · No harm found
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-31
K-0363
E · No harm found
Install corridor and hallway doors that block smoke.
Corrected 2026-01-31
K-0541
F · No harm found
Install properly constructed and protected linen or trash chutes.
Corrected 2026-01-31
K-0741
F · No harm found
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-01-31
K-0918
F · No harm found
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-31
K-0927
E · No harm found
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-01-31
2024-04-10Fire-safety inspection12 citations
K-0231
D · No harm found
Provide large enough exits.
Corrected 2024-07-01
K-0291
F · No harm found
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-01
K-0324
D · No harm found
Provide properly protected cooking facilities.
Corrected 2024-07-28
K-0345
F · No harm found
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-28
K-0353
F · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-01
K-0355
F · No harm found
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-01
K-0363
F · No harm found
Install corridor and hallway doors that block smoke.
Corrected 2024-06-28
K-0521
F · No harm found
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-28
K-0712
F · No harm found
Have simulated fire drills held at unexpected times.
Corrected 2024-07-01
K-0914
F · No harm found
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-01
K-0918
F · No harm found
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-28
K-0923
F · No harm found
Have proper medical gas storage and administration areas.
Corrected 2024-07-01
2022-11-17Fire-safety inspection20 citations
E-0001
F · No harm found
Establish an Emergency Preparedness Program (EP).
Corrected 2022-12-17
E-0004
F · No harm found
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-17
E-0013
F · No harm found
Develop Emergency Preparedness policies and procedures.
Corrected 2022-12-17
E-0029
F · No harm found
Develop a communication plan.
Corrected 2022-12-17
E-0036
F · No harm found
Establish emergency prep training and testing.
Corrected 2022-12-17
K-0222
F · No harm found
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.
Corrected 2023-03-31
K-0271
F · No harm found
Have exits that are accessible at all times.
Corrected 2022-12-30
K-0291
F · No harm found
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-30
K-0293
F · No harm found
Have properly located and lighted "Exit" signs.
Corrected 2022-12-30
K-0321
F · No harm found
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-30
K-0324
E · No harm found
Provide properly protected cooking facilities.
Corrected 2022-12-30
K-0341
E · No harm found
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-03-31
K-0345
F · No harm found
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
K-0351
F · No harm found
Install an approved automatic sprinkler system.
Corrected 2023-03-31
K-0353
F · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
K-0364
E · No harm found
Install properly constructed windows in hallway walls or doors.
Corrected 2022-12-30
K-0371
E · No harm found
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-03-31
K-0521
F · No harm found
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-31
K-0541
F · No harm found
Install properly constructed and protected linen or trash chutes.
Corrected 2022-12-30
K-0712
F · No harm found
Have simulated fire drills held at unexpected times.
Corrected 2022-12-30
Federal penalties
2025-01-29Fine$53,151
2024-04-10Fine$52,416
2023-10-09Fine$111,704
2025-01-29Medicare payment denial — 8 days
2023-10-09Medicare payment denial — 21 days
Total fines$217,271
Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 065248.
Visitor reviews
What people say on Google.
4.7★★★★★55 ratings on Google
★★★★★Carey Gordon · 2026-07-05 · via Google“Our Grandma is in hospice and every visit has been nice. The staff has been so loving. We visit her weekly and we have other family that visits her too. Her room has enough space for us to gather and we can take her outside or to other areas if she wants. The amount of rounds and check-ins have been consistent and I feel good that she’s in good hands. The front desk gal is the sweetest. From the m…”
★★★★★Danna Roberts · 2026-01-11 · via Google“From the reception its to the nursing staff the do their best to give great care. I spend time feeding mom, going to church services (video) and just love some of patients who seem happy but sad to be in the care center. Mom has dementia, good and bad days, but the staff love her. I'm glad she's there for now. Danna”
★★★★Kristi O’Dea · 2026-03-25 · via Google“My son has been living at the facility since 2014. He is now 46 years old. Staff are very friendly and he is quite popular there. He delivers mail and packages to the residents to earn a little income. I would agree with another reviewer. The smell and stench of urine walking to my son’s room can be quite awful some days!”
Ratings and reviews are from Google and reflect visitor opinions, not our verification. See all reviews on Google
Inside your report
What unlocks when you order.
Ownership & corporate history
Primary tierPrior operators & transfers
Corporate network & affiliates
,
Owners' other facilities
· · 2 more
Inspection citations — last 5 years
LockedThe 118 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.
Civil & criminal lawsuits
Advanced tier onlyActive civil suits
#
Federal dockets
CDC infection data
Unlock the full file
Citations, owner history, lawsuits — decoded into one PDF.
Original records
Sources we pull for this facility.
Source
CMS Nursing Home Compare
data.cms.gov Provider Data Catalog
Last verified 2026-08-31
Source
Google Business Profile
Photos, reviews & hours
Displayed with attribution · refreshed on re-run
Source
Secretary of State filings
Entity & officer search
Pulled when a report is ordered
Source
PACER federal dockets
pacer.uscourts.gov
Pulled when a report is ordered