Oakwood Care and Rehabilitation, Lakewood, Colorado

72
Citations from health inspectionsColorado average: 25 a home: 10
Residents harmed or put in dangerColorado average: 2.3 a home: $217,271
Fines from the federal governmentColorado average: $22,802 a home: 1 out of 5
Overall rating in starsColorado average: 3.2

The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files

Eight inspection visits produced 72 citations. Residents were in immediate danger in one finding. Residents were found hurt in nine cases. Federal fines came to $217,271 (three fines). Two times, Medicare stopped paying for new admissions.

The CMS abuse icon is shown for this home. Care Compare adds it after a citation for abuse or neglect. Either a resident was harmed recently, or harm could have resulted over two inspections in a row.

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Quick Look at the Record

The home's overall star rating: 1 out of 5
Rating for health inspections: 1 out of 5
Rating for staffing: 3 out of 5
Rating for quality of care: 4 out of 5
Nurse time for each resident: 3.00 hours each dayThe Colorado average is 3.72 hours
Time from registered nurses: 0.50 hours each dayThe Colorado average is 0.82 hours
Nursing staff who left during one year: 53.7%against the Colorado average of 47.1%
Beds that are certified: 170
Ownership: Corporation (for profit)
Chain: The Ensign Group, with 344 homes
Street address: 5301 W 1st Ave, Lakewood, Colorado 80226
County: Jefferson

Each inspection's citations

Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.

Six citations dated Feb. 26, 2026

F943 Staff Training on Abuse, Neglect, and Dementia: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F867 Ongoing Quality Review Group and Correction Plans: risk of harm, no one found hurt, widespread, found on a complaint visit.
F744 Proper Dementia Treatment and Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

Four citations dated Dec. 18, 2025

F658 Care That Meets Professional Standards: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F580 Telling the Family About a Change: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F553 Resident Involvement in Care Planning: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

Six citations dated Sept. 11, 2025

F947 Nurse Aide Skills, Dementia, and Abuse Training: risk of harm, no one found hurt, one or a few residents.
F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread, found on a complaint visit.
F730 Review Nurse Aide Performance and Training: risk of harm, no one found hurt, one or a few residents.
F679 Activities That Meet Every Resident's Needs: risk of harm, no one found hurt, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents.

Three citations dated June 12, 2025

F760 Significant Medication Errors: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F628 Required Transfer Paperwork and Notices: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

Six citations dated Jan. 29, 2025

F880 Infection Prevention and Control: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F804 Food Taste and Temperature: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F744 Proper Dementia Treatment and Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: residents were harmed, one or a few residents, found on a complaint visit.

16 citations dated April 10, 2024

F921 A Safe, Clean Building: risk of harm, no one found hurt, a pattern, several residents.
F883 Flu and Pneumonia Vaccines: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F880 Infection Prevention and Control: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F791 Dental Services for Residents: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, one or a few residents.
F758 Psychotropic Drugs and PRN Orders: risk of harm, no one found hurt, one or a few residents.
F744 Proper Dementia Treatment and Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F697 Pain Management: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
F685 Help Getting Vision and Hearing Care: risk of harm, no one found hurt, a pattern, several residents.
F684 Quality of Care: risk of harm, no one found hurt, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: residents were harmed, one or a few residents, found on a complaint visit.
F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.

13 citations dated Oct. 9, 2023

F867 Ongoing Quality Review Group and Correction Plans: risk of harm, no one found hurt, widespread, found on a complaint visit.
F842 Medical Records and Privacy: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F838 Facility Wide Assessment of Needed Resources: risk of harm, no one found hurt, widespread, found on a complaint visit.
F745 Medically Related Social Services: residents were harmed, one or a few residents, found on a complaint visit.
F744 Proper Dementia Treatment and Services: residents were harmed, one or a few residents, found on a complaint visit.
F730 Review Nurse Aide Performance and Training: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F697 Pain Management: residents were harmed, one or a few residents, found on a complaint visit.
F684 Quality of Care: residents were harmed, one or a few residents, found on a complaint visit.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F600 Freedom From Abuse and Neglect: immediate danger to residents, a pattern, several residents, found on a complaint visit.
F577 Access to Inspection Results and Advocates: minimal risk to residents, widespread, found on a complaint visit.
F550 Dignity and Resident Rights: residents were harmed, one or a few residents, found on a complaint visit.

18 citations dated Nov. 17, 2022

F849 Arrange Hospice Care When Needed: risk of harm, no one found hurt, one or a few residents.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents.
F803 Menus That Meet Nutrition Needs: risk of harm, no one found hurt, one or a few residents.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, a pattern, several residents.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents.
F689 Accident Hazards and Supervision: residents were harmed, one or a few residents.
F686 Pressure Ulcer (Bedsore) Care: residents were harmed, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents.
F676 Help Residents Keep Daily Living Abilities: risk of harm, no one found hurt, one or a few residents.
F644 Coordinate Assessments With Mental Health Screening Program: risk of harm, no one found hurt, one or a few residents.
F623 Notice Before Transfer or Discharge: risk of harm, no one found hurt, one or a few residents.
F622 Valid Reasons and Paperwork for Transfer or Discharge: risk of harm, no one found hurt, one or a few residents.
F600 Freedom From Abuse and Neglect: risk of harm, no one found hurt, a pattern, several residents.
F584 A Safe, Clean, Homelike Room: risk of harm, no one found hurt, a pattern, several residents.
F568 Properly Manage Resident Money Held by Facility: risk of harm, no one found hurt, one or a few residents.
F567 Right to Manage Own Finances: risk of harm, no one found hurt, one or a few residents.

Payment Denials and Fines

Date	Penalty	Amount
Jan. 29, 2025	Fine	$53,151
Jan. 29, 2025	Payment denial for new admissions	eight days
April 10, 2024	Fine	$52,416
Oct. 9, 2023	Fine	$111,704
Oct. 9, 2023	Payment denial for new admissions	21 days

Ownership and Management of the Home

The home is run by Kare Technologies LLC (operational or managerial control).
The home is run by Onshift Inc. (operational or managerial control).
The home is run by Sos Nursing Services, Inc. (operational or managerial control).

The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 065248. Other homes in Colorado.