F53

OAKWOOD CARE AND REHABILITATION

Grade F 53/100 composite score

For profit - CorporationSFF CandidateAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

170

Ownership

For profit - Corporation

Total Fines

$235,923

Last Survey

N/A

5301 W 1ST AVE, LAKEWOOD, CO 80226
3032388333

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.69h
LPN
0.67h
CNA
2.26h
Total
3.62h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

ENDURA HEALTHCARE LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2023

100%

THE ENSIGN GROUP INC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2006

100%

KARE TECHNOLOGIES LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

ONSHIFT INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

SOS NURSING SERVICES, INC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Mar 2024

BOYLES, EDDY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Dec 2023

GAHM, GREGORY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2024

JORGENSEN, DAVID

IndividualCORPORATE DIRECTORSince Sep 2024

BURNAM, SOON

IndividualCORPORATE OFFICERSince Dec 2023

DUNYON, DAVID

IndividualCORPORATE OFFICERSince Mar 2024

KEETCH, CHAD

IndividualCORPORATE OFFICERSince Mar 2011

SATO, AMI

IndividualCORPORATE OFFICERSince Sep 2024

Penalties & Fines (6)

$235,923total fines
DateTypeDescriptionAmount
Jan 29, 2025Fine$53,151
Jan 29, 2025Payment Denial
Apr 10, 2024Fine$52,416
Oct 9, 2023Fine$111,704
Oct 9, 2023Payment Denial
May 4, 2023Fine$18,652

Health Inspection Deficiencies (65)

September 11, 2025Health6 deficiencies
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 10, 2025
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Oct 10, 2025
0730DMinimal harm, Isolated

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Oct 10, 2025
0947DMinimal harm, Isolated

Ensure 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 Services Deficiencies

Corrected Oct 10, 2025
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 10, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 10, 2025
June 12, 2025Health3 deficiencies
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Jul 4, 2025
0628DMinimal harm, Isolated

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies

Corrected Jul 4, 2025
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Jul 4, 2025
January 29, 2025Health6 deficiencies1 severe
0600GActual harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 7, 2025
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 7, 2025
0744DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected Mar 7, 2025
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Mar 7, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Mar 7, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 7, 2025
April 10, 2024Health16 deficiencies1 severe
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0685EMinimal harm, Pattern

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0690DMinimal harm, Isolated

Provide 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 Care Deficiencies

Corrected May 2, 2024
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected May 5, 2024
0761DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected May 2, 2024
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected May 5, 2024
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected May 2, 2024
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected May 5, 2024
0600GActual harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 5, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 5, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0744EMinimal harm, Pattern

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0791EMinimal harm, Pattern

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected May 5, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 2, 2024
0883EMinimal harm, Pattern

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected May 2, 2024
October 9, 2023Health13 deficiencies6 severe
0550GActual harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Nov 9, 2023
0577CNo harm, Widespread

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies

Corrected Nov 9, 2023
0600KImmediate jeopardy, Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 24, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 28, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 9, 2023
0684GActual harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Nov 9, 2023
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Nov 9, 2023
0730EMinimal harm, Pattern

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Nov 9, 2023
0744GActual harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

Corrected Nov 9, 2023
0745GActual harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Nov 9, 2023
0838FMinimal harm, Widespread

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.

Administration Deficiencies

Corrected Nov 9, 2023
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 9, 2023
0867FMinimal harm, Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Nov 9, 2023
July 20, 2023Health2 deficiencies
0814FMinimal harm, Widespread

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Aug 11, 2023
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 11, 2023
May 4, 2023Health1 deficiency1 severe
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jun 2, 2023
November 17, 2022Health18 deficiencies2 severe
0567DMinimal harm, Isolated

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0568DMinimal harm, Isolated

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0600EMinimal harm, Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 17, 2022
0622DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0623DMinimal harm, Isolated

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Corrected Dec 17, 2022
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 17, 2022
0676DMinimal harm, Isolated

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Dec 23, 2022
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Dec 22, 2022
0690DMinimal harm, Isolated

Provide 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 Care Deficiencies

Corrected Dec 17, 2022
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Dec 17, 2022
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Dec 17, 2022
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Dec 17, 2022
0803DMinimal harm, Isolated

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.

Nutrition and Dietary Deficiencies

Corrected Dec 17, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Dec 17, 2022
0849DMinimal harm, Isolated

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.

Administration Deficiencies

Corrected Dec 17, 2022

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Frequently Asked Questions

What is the CareGrader rating for OAKWOOD CARE AND REHABILITATION?

OAKWOOD CARE AND REHABILITATION in LAKEWOOD, Colorado has a CareGrader grade of F (Poor), with a composite score of 53.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for OAKWOOD CARE AND REHABILITATION?

OAKWOOD CARE AND REHABILITATION has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does OAKWOOD CARE AND REHABILITATION have?

OAKWOOD CARE AND REHABILITATION has 65 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has OAKWOOD CARE AND REHABILITATION been fined?

Yes. OAKWOOD CARE AND REHABILITATION has $235,923 in total fines from CMS enforcement actions across 6 penalties.

How many beds does OAKWOOD CARE AND REHABILITATION have?

OAKWOOD CARE AND REHABILITATION has 170 certified beds with approximately 108 current residents (64% occupancy). The facility is located at 5301 W 1ST AVE, LAKEWOOD, Colorado 80226. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.