Facility WatchInspection records for every certified US nursing home
Oakwood Care and Rehabilitation
5301 W 1st AVE Lakewood, CO 80226 (303) 238-8333
Abuse icon
CCN
065248
Certified beds
170
Ownership
For profit - Corporation
Chain
THE Ensign Group
Nurse staffing
3.57
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.66 hours per resident per day
Nursing staff turnover: 50% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected February 26, 2026
6 citations · from a complaint investigation · Health
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected March 23, 2026
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected March 23, 2026
E
F0600No actual harm with potential for more than minimal harm · Pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected March 23, 2026
E
F0744No actual harm with potential for more than minimal harm · Pattern
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected March 23, 2026
E
F0943No actual harm with potential for more than minimal harm · Pattern
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected March 23, 2026
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected March 23, 2026
Inspected December 18, 2025
4 citations · from a complaint investigation · Health
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected December 31, 2025
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected January 15, 2026
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected January 15, 2026
E
F0584No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 23, 2025
Inspected September 11, 2025
6 citations · from a complaint investigation · Health
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected October 10, 2025
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected October 10, 2025
D
F0730No actual harm with potential for more than minimal harm · Isolated
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected October 10, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected October 10, 2025
D
F0947No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected October 10, 2025
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 10, 2025
Inspected June 12, 2025
3 citations · from a complaint investigation · Health
D
F0628No actual harm with potential for more than minimal harm · Isolated
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Deficient, Provider has date of correction · corrected July 4, 2025
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected July 4, 2025
E
F0550No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected July 4, 2025
Inspected January 29, 2025
6 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0744No actual harm with potential for more than minimal harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 7, 2025
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected March 7, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 7, 2025
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected March 7, 2025
Inspected April 10, 2024
16 citations · from a complaint investigation · Health
D
F0561No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0584No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0690No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected May 2, 2024
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0758No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected May 5, 2024
D
F0761No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected May 2, 2024
E
F0685No actual harm with potential for more than minimal harm · Pattern
Assist a resident in gaining access to vision and hearing services.
Deficient, Provider has date of correction · corrected May 5, 2024
E
F0744No actual harm with potential for more than minimal harm · Pattern
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected May 5, 2024
E
F0791No actual harm with potential for more than minimal harm · Pattern
Provide or obtain dental services for each resident.
Deficient, Provider has date of correction · corrected May 5, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected May 2, 2024
E
F0883No actual harm with potential for more than minimal harm · Pattern
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected May 2, 2024
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected May 5, 2024
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected May 5, 2024
Inspected October 9, 2023
13 citations · from a complaint investigation · Health
C
F0577No actual harm with potential for minimal harm · Widespread
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Deficient, Provider has date of correction · corrected November 9, 2023
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected November 28, 2023
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected November 9, 2023
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected November 9, 2023
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected November 9, 2023
F
F0838No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected November 9, 2023
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected November 9, 2023
G
F0550Actual harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected November 9, 2023
G
F0684Actual harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected November 9, 2023
G
F0697Actual harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected November 9, 2023
G
F0744Actual harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected November 9, 2023
G
F0745Actual harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected November 9, 2023
K
F0600Immediate jeopardy to resident health or safety · Pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected November 24, 2023
Inspected July 20, 2023
2 citations · from a complaint investigation · Health
F
F0814No actual harm with potential for more than minimal harm · Widespread
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected August 11, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 11, 2023
Inspected November 17, 2022
18 citations · Health
D
F0567No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to manage his or her financial affairs.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0568No actual harm with potential for more than minimal harm · Isolated
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0622No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0644No actual harm with potential for more than minimal harm · Isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0676No actual harm with potential for more than minimal harm · Isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0690No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0803No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
D
F0849No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0584No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0600No actual harm with potential for more than minimal harm · Pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0761No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 17, 2022
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected December 17, 2022
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected December 23, 2022
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected December 22, 2022
Penalties
Date
Type
Amount
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
Ownership transfers
Effective
Seller
Buyer
03/01/2024
Bethany Nursing & Rehab Center LLC
FOX Hollow Healthcare INC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.