Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

C+
Grade
44
Score
CMS Ratings
8.1/22
Staffing Quality
8.1/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
5.0/13
Availability
10.0/10

Current Availability Estimate

Occupancy Rate74.2%
170
Total Beds
126
Occupied
44
Available

Basic Information

Address:

5301 W 1ST AVE

LAKEWOOD, CO 80226

Number of Beds:

170

Estimated Occupancy:

74% (~44 available)

Chain:

THE ENSIGN GROUP

Quality Ratings

Overall Rating:1/5 Stars
Health Inspection:1/5 Stars
Staffing Rating:3/5 Stars
Quality Measures:4/5 Stars

Safety Information

Abuse Issues:Yes - Has Issues
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

065248

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.50

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Below Average

This Facility

3.00

hours

National Avg

3.89

hours

Breakdown:

RN: 0.50hLPN: 0.56hAide: 1.95h

Staff Turnover Rate

Annual nursing staff turnover

Above Average

This Facility

53.7%

National Avg

46.6%

RN Turnover: 50.0%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 4 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

162

Inspections

7

Critical

4

High

20

Jan 29, 2025 - Health Survey

12 deficiencies cited

Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Mar 7, 2025From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0804

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Mar 7, 2025From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Mar 7, 2025From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Mar 7, 2025From Complaint

Apr 10, 2024 - Health Survey

32 deficiencies cited

Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 5, 2024
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: May 5, 2024
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: May 2, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: May 5, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: May 2, 2024
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: May 5, 2024
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: May 5, 2024From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: May 5, 2024
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: May 5, 2024
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: May 2, 2024
Medium - PatternTag F0758

Pharmacy Service Deficiencies

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.

Corrected: May 5, 2024
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: May 2, 2024
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: May 5, 2024
Medium - PatternTag F0561

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: May 5, 2024From Complaint
High - Widespread PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0791

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Corrected: May 5, 2024From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: May 2, 2024From Complaint
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: May 5, 2024From Complaint

Oct 9, 2023 - Health Survey

26 deficiencies cited

High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Nov 28, 2023From Complaint
Critical - Actual HarmTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Nov 24, 2023From Complaint
Low - IsolatedTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Nov 28, 2023From Complaint
Critical - Actual HarmTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Nov 24, 2023From Complaint
Low - IsolatedTag F0577

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0838

Administration Deficiencies

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.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

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

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0838

Administration Deficiencies

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.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0745

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0744

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

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

Corrected: Nov 9, 2023From Complaint
High - Widespread PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Nov 9, 2023From Complaint
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Nov 9, 2023From Complaint

Jul 20, 2023 - Health Survey

4 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 11, 2023From Complaint
Medium - PatternTag F0814

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Corrected: Aug 11, 2023From Complaint
Medium - PatternTag F0814

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

Corrected: Aug 11, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Aug 11, 2023From Complaint

May 4, 2023 - Health Survey

2 deficiencies cited

Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 2, 2023From Complaint
Critical - Actual HarmTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 2, 2023From Complaint

Nov 17, 2022 - Health Survey

36 deficiencies cited

Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Dec 17, 2022
High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 22, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Dec 17, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Dec 17, 2022
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Dec 17, 2022
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Dec 17, 2022
Medium - PatternTag F0849

Administration Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Dec 17, 2022From Complaint
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Dec 17, 2022From Complaint
Medium - PatternTag F0567

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Corrected: Dec 17, 2022
Medium - PatternTag F0568

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected: Dec 17, 2022
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Dec 17, 2022
Medium - PatternTag F0622

Resident Rights Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 17, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

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

Corrected: Dec 17, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Dec 23, 2022
High - Widespread PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 22, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Dec 17, 2022
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Dec 17, 2022
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Dec 17, 2022
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

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

Corrected: Dec 17, 2022
Medium - PatternTag F0849

Administration Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Dec 17, 2022From Complaint
Medium - PatternTag F0676

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected: Dec 17, 2022From Complaint
Medium - PatternTag F0567

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Corrected: Dec 17, 2022
Medium - PatternTag F0568

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected: Dec 17, 2022
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Dec 17, 2022
Medium - PatternTag F0622

Resident Rights Deficiencies

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.

Corrected: Dec 17, 2022
Medium - PatternTag F0644

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected: Dec 17, 2022
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Dec 23, 2022

Sep 8, 2021 - Health Survey

50 deficiencies cited

Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Oct 7, 2021
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 7, 2021
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Oct 7, 2021
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Oct 7, 2021
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 7, 2021
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Oct 7, 2021
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Oct 7, 2021
Medium - PatternTag F0568

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected: Oct 7, 2021
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Oct 7, 2021
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Oct 7, 2021
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Oct 7, 2021
Medium - PatternTag F0622

Resident Rights Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Oct 7, 2021
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Oct 7, 2021
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Oct 7, 2021
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Oct 7, 2021
Medium - PatternTag F0622

Resident Rights Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Oct 7, 2021
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Oct 7, 2021
Medium - PatternTag F0584

Resident Rights Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0578

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected: Oct 7, 2021
Medium - PatternTag F0568

Resident Rights Deficiencies

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected: Oct 7, 2021
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Oct 7, 2021
Medium - PatternTag F0661

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected: Oct 7, 2021
Medium - PatternTag F0661

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected: Oct 7, 2021
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Oct 7, 2021
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Oct 7, 2021
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Oct 7, 2021
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

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

Corrected: Oct 7, 2021
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 7, 2021
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Oct 7, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 7, 2021
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Oct 7, 2021
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Oct 7, 2021
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Oct 7, 2021
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Corrected: Oct 7, 2021
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Oct 7, 2021
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 7, 2021
Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Oct 7, 2021
Medium - PatternTag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected: Oct 7, 2021
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Oct 7, 2021
Medium - PatternTag F0867

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected: Oct 7, 2021
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Corrected: Oct 7, 2021
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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.

Corrected: Oct 7, 2021
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Oct 7, 2021
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Oct 7, 2021
Medium - PatternTag F0697

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Corrected: Oct 7, 2021
Medium - PatternTag F0695

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Corrected: Oct 7, 2021

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

5 penalties in the past 3 years

Total fines: $217,271

FineJanuary 29, 2025

$53,151

Data processed: August 1, 2026

Payment DenialJanuary 29, 2025

Payment Denial: Started February 27, 2025

Duration: 8 days

Data processed: August 1, 2026

FineApril 10, 2024

$52,416

Data processed: August 1, 2026

FineOctober 9, 2023

$111,704

Data processed: August 1, 2026

Payment DenialOctober 9, 2023

Payment Denial: Started November 7, 2023

Duration: 21 days

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

🛏
Beds Available
Approximately 44 beds potentially available
🏢
Part of Healthcare Chain
THE ENSIGN GROUP

Frequently Asked Questions

What is the quality rating for OAKWOOD CARE AND REHABILITATION?

OAKWOOD CARE AND REHABILITATION has an overall CMS rating of 1 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

OAKWOOD CARE AND REHABILITATION has 170 certified beds. The facility averages 126 residents per day, with an occupancy rate of approximately 74%.

What type of ownership does this facility have?

This facility is for profit - corporation owned. It is part of the THE ENSIGN GROUP network.

How can I contact OAKWOOD CARE AND REHABILITATION?

You can call OAKWOOD CARE AND REHABILITATION at (303)238-8333. The facility is located at 5301 W 1ST AVE, LAKEWOOD, CO 80226.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: