Nursing Care Index

Oakwood Care And Rehabilitation

Lakewood, Jefferson County, Colorado · CCN 065248 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)

CMS rates Oakwood Care And Rehabilitation 1 of 5 overall as of August 2026. 170 certified beds, 126 residents a day on average. 72 citations on record from the current inspection cycles, 1 at immediate jeopardy; 3 fines totalling $217,271 and 2 payment denials.

On record

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay3 / 4 of 5

Staffing

Total nurse staffing3.00127 hours per resident per day
Registered nurses0.4971 hours per resident per day
Weekend total2.80553 hours per resident per day
Nursing staff turnover53.7% (registered nurses 50%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-02-26
complaint survey
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2026-03-23
2026-02-26
complaint survey
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 · tag F0600
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-23
2026-02-26
complaint survey
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-23
2026-02-26
complaint survey
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0943
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-03-23
2026-02-26
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-23
2026-02-26
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-23
2025-12-18
complaint survey
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 · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-23
2025-12-18
complaint survey
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Resident Rights Deficiencies · tag F0553
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-31
2025-12-18
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-15
2025-12-18
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-15
2025-09-11
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-10-10
2025-09-11 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-09-11 Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies · tag F0679
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-09-11 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-09-11
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-09-11 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 · tag F0947
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-10-10
2025-06-12
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-04
2025-06-12
complaint survey
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-04
2025-06-12
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-04
2025-01-29
complaint survey
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 · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-03-07
2025-01-29
complaint survey
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-07
2025-01-29
complaint survey
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-03-07
2025-01-29
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-07
2025-01-29
complaint survey
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-07
2025-01-29
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-07
2024-04-10
complaint survey
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 · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10 Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies · tag F0685
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies · tag F0791
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-02
2024-04-10
complaint survey
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · tag F0883
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-02
2024-04-10 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Environmental Deficiencies · tag F0921
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · tag F0561
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-02
2024-04-10
complaint survey
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 · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10 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 · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-02
2024-04-10
complaint survey
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10 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 · tag F0758
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-05
2024-04-10 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 · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-02
2023-10-09
complaint survey
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 · tag F0600
K Immediate jeopardy to resident health or safety; pattern Deficient, Provider has date of correction
2023-11-24
2023-10-09
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
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 · tag F0838
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-28
2023-10-09
complaint survey
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
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 · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-09
2023-10-09
complaint survey
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Resident Rights Deficiencies · tag F0577
C No actual harm, with potential for minimal harm; widespread Deficient, Provider has date of correction
2023-11-09
2022-11-17 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2022-12-23
2022-11-17 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2022-12-22
2022-11-17 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 · tag F0584
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0600
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-12-17
2022-11-17 Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies · tag F0567
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Resident Rights Deficiencies · tag F0568
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0676
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0803
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17
2022-11-17 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 · tag F0849
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-12-17

Fines and payment denials

DatePenaltyAmount
2025-01-29Payment denial for 8 days from 2025-02-27
2025-01-29Fine$53,151
2024-04-10Fine$52,416
2023-10-09Payment denial for 21 days from 2023-11-07
2023-10-09Fine$111,704

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Caretrust Gp LLC
Organization
adp of the snf2024-03-01
Caretrust Reit Inc.
Organization
adp of the snf2024-03-01
Ctr Partnership Lp
Organization
adp of the snf2024-03-01
Ensign Services Inc.
Organization
adp of the snf2023-12-18
Kare Technologies LLC
Organization
operational/managerial control2024-03-01
Onshift Inc.
Organization
operational/managerial control2024-03-01
Sos Nursing Services, Inc.
Organization
operational/managerial control2024-03-01
Boyles, Eddy
Individual
adp of the snf2025-07-15
Burnam, Soon
Individual
adp of the snf2025-07-15
Gahm, Gregory
Individual
adp of the snf2025-07-15
Jorgensen, David
Individual
corporate director2024-09-09
Burnam, Soon
Individual
corporate officer2023-12-18
Dunyon, David
Individual
corporate officer2024-03-01
Keetch, Chad
Individual
corporate officer2011-03-01
Sato, Ami
Individual
corporate officer2024-09-09
Port, Barry
Individual
individual is an owner, partner or trustee of any adp of the snf2025-07-15
Boyles, Eddy
Individual
managing control - governing body2023-12-18
Gahm, Gregory
Individual
managing control - governing body2024-06-26
Boyles, Eddy
Individual
operational/managerial control2023-12-18
Gahm, Gregory
Individual
operational/managerial control2024-06-26

What changed

Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.

Tell me when this record changes

One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Oakwood Care And Rehabilitation.

Double opt-in. One email per change, unsubscribe in one click. No newsletter. Privacy policy.

Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Jefferson County.