OAKWOOD CARE AND REHABILITATION

LAKEWOOD, CO · 170 beds · For profit - Corporation

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 1-star health inspection rating (lowest possible)
  • 2 citation(s) at the highest severity level — immediate risk to residents
  • 9 citation(s) where residents suffered actual harm
  • $235,923 in fines over 3 years

Green Flags

No positive signals identified yet.

Quick Facts

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
13
1.4x state avg
Deficiencies
$235,923
Fines (3-yr)
★★★☆☆
Staffing

Violation Timeline

December 17, 2025

8 deficiencyies
F0553 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Allow resident to participate in the development and implementation of his or her person-centered plan of care.

F0580 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

F0584 Potential Harm Scope/Severity: E

Resident Rights Deficiencies

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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.

F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure services provided by the nursing facility meet professional standards of quality.

F0553 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

Show details

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

F0580 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

Show details

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

F0584 Potential Harm Scope/Severity: E

Resident Rights Deficiencies

Show details

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.

F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Ensure services provided by the nursing facility meet professional standards of quality.

September 10, 2025

12 deficiencyies
F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide care and assistance to perform activities of daily living for any resident who is unable.

F0679 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide activities to meet all resident's needs.

F0730 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Observe each nurse aide's job performance and give regular training.

F0947 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

Show details

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

Show details

Provide and implement an infection prevention and control program.

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide care and assistance to perform activities of daily living for any resident who is unable.

F0679 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide activities to meet all resident's needs.

F0730 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

Show details

Observe each nurse aide's job performance and give regular training.

F0947 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

Show details

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

Show details

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

See full violation history →

Staffing

0.69
RN hrs/res/day
0.67
LPN hrs/res/day
2.26
CNA hrs/res/day
3.30
Weekend hrs/res/day
48%
Total nurse turnover
31%
RN turnover

A nurse checks on each resident roughly every 6.6 hours on average.

Fines & Penalties

  • Fine Jan 28, 2025
    $53,151
  • Payment Denial Jan 28, 2025
    Payment Denial
  • Fine Apr 9, 2024
    $52,416
  • Fine Oct 8, 2023
    $111,704
  • Payment Denial Oct 8, 2023
    Payment Denial
  • Fine May 3, 2023
    $18,652
Total $235,923

Ownership

For profit - Corporation Chain: THE ENSIGN GROUP
  • ENDURA HEALTHCARE LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 12/18/2023

    100% Organization
  • THE ENSIGN GROUP INC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 01/30/2006

    100% Organization
  • KARE TECHNOLOGIES LLC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/01/2024

    Organization
  • ONSHIFT INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/01/2024

    Organization
  • SOS NURSING SERVICES, INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 03/01/2024

    Organization
  • BOYLES, EDDY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 12/18/2023

    Individual
  • GAHM, GREGORY

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 06/26/2024

    Individual
  • JORGENSEN, DAVID

    CORPORATE DIRECTOR

    Since since 09/09/2024

    Individual
  • BURNAM, SOON

    CORPORATE OFFICER

    Since since 12/18/2023

    Individual
  • DUNYON, DAVID

    CORPORATE OFFICER

    Since since 03/01/2024

    Individual
  • KEETCH, CHAD

    CORPORATE OFFICER

    Since since 03/01/2011

    Individual
  • SATO, AMI

    CORPORATE OFFICER

    Since since 09/09/2024

    Individual

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