The nursing home failed to protect residents from abuse and neglect by others. Cited October 2023 — limited pattern, immediate jeopardy to residents.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: K
Nursing home report
OAKWOOD CARE AND REHABILITATION
LAKEWOOD, CO · Medicare-certified · 170 beds
Needs attention
Special Focus candidateAbuse citationFor-profitChain member
1 of 5 overall
OAKWOOD CARE AND REHABILITATION in Lakewood, CO has a 1 out of 5 star overall rating, with very low health inspection results and special-focus candidate status. Staffing is 2.90 hours per resident per day versus the 4.1 federal benchmark, and it has had $53,151 in fines in the last 24 months.
Facility ratings
Health inspections
Staffing
2.9003 hrs/resident/day
Quality measures
Last inspection: February 26, 2026Penalties, last 24 months: $53,151special focus facility
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.9003.
Staffing detail
- Registered nurses
- 0.53
- Licensed practical nurses
- 0.56
- Nurse aides
- 1.80
- Weekend nursing
- 2.67
Hours per resident per day.
Total staff turnover: 51%
Registered nurse turnover: 50%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
20.7%Worsening
Residents with a fall causing major injury
2.1%Worsening
Residents with pressure ulcers (bedsores)
3.2%Worsening
Residents with a urinary tract infection
0.7%Improving
Residents who lost too much weight
5.9%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
29.6%Improving
Residents whose ability to walk got worse
22.8%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
9%Worsening
Short-stay residents newly given an antipsychotic
7.5%Steady
Residents with a long-term catheter
1.1%Improving
Residents with new or worsening incontinence
30%Worsening
Residents with depressive symptoms
19.9%Improving
Long-stay residents given the seasonal flu vaccine
94.2%Steady
Long-stay residents given the pneumonia vaccine
97.4%Worsening
Short-stay residents given the seasonal flu vaccine
62.5%Steady
Short-stay residents given the pneumonia vaccine
60.3%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2023 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The home failed to provide the appropriate treatment and services for a resident with dementia. Cited October 2023 — isolated incident, actual harm.
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F-Tag 744 — 42 CFR §483.40(b)(3) — S/S: G
The home failed to ensure residents were treated with dignity and could make their own choices and communicate freely. Cited October 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 550 — 42 CFR §483.10(a) — S/S: G
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited October 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $53,151 was recorded.
Penalties & enforcement
On record with Medicare: 3 fines · $217,271 in total fines · 2 payment denials.
- 8 days
Medicare/Medicaid payment denial
Jan 29, 2025
- $53,151
Federal fine
Jan 29, 2025
- $52,416
Federal fine
Apr 10, 2024
- 21 days
Medicare/Medicaid payment denial
Oct 9, 2023
- $111,704
Federal fine
Oct 9, 2023
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 118.6 residents on an average day (70% of 170 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 37 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.