Facility Watch Inspection 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
F0610 No 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
F0677 No 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
F0600 No 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
F0744 No 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
F0943 No 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
F0867 No 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
F0553 No 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
F0580 No 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
F0658 No 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
F0584 No 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
F0677 No 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
F0679 No 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
F0730 No 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
F0880 No 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
F0947 No 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
F0812 No 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
F0628 No 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
F0760 No 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
F0550 No 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
F0609 No 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
F0744 No 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
F0880 No 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
F0804 No 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
F0812 No 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
F0600 Actual 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
F0561 No 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
F0584 No 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
F0610 No 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
F0677 No 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
F0684 No 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
F0690 No 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
F0697 No 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
F0758 No 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
F0761 No 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
F0685 No 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
F0744 No 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
F0791 No 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
F0880 No 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
F0883 No 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
F0921 No 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
F0600 Actual 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
F0577 No 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
F0609 No 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
F0610 No 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
F0842 No 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
F0730 No 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
F0838 No 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
F0867 No 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
F0550 Actual 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
F0684 Actual 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
F0697 Actual 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
F0744 Actual 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
F0745 Actual 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
F0600 Immediate 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
F0814 No 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
F0880 No 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
F0567 No 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
F0568 No 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
F0622 No 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
F0623 No 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
F0644 No 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
F0676 No 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
F0690 No 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
F0757 No 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
F0803 No 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
F0849 No 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
F0584 No 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
F0600 No 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
F0677 No 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
F0695 No 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
F0761 No 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
F0812 No 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
F0686 Actual harm · Isolated

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

Deficient, Provider has date of correction · corrected December 23, 2022
G
F0689 Actual 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

DateTypeAmount
January 29, 2025Fine$53,151
January 29, 2025Payment Denial · 8 days
April 10, 2024Fine$52,416
October 9, 2023Fine$111,704
October 9, 2023Payment Denial · 21 days

Ownership transfers

EffectiveSellerBuyer
03/01/2024Bethany Nursing & Rehab Center LLCFOX Hollow Healthcare INC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.