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Nursing HomeMedicaid Investigative

Oakwood Care and Rehabilitation

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

5301 W 1st Ave, East Gate · Lakewood, CO 80226170 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 51 Google reviews

5
4
3
2
1
Oakwood Care and Rehabilitation Nursing Home in Lakewood, CO — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (13 vs median 7)

Bottom 25% in CO · Below recommended RN staffing · Worst in THE ENSIGN GROUP chain · $235,923 in fines

Source: Medicare data

What this means for your family

Oakwood is highly regarded for its compassionate staff and welcoming environment, making it a strong contender for those prioritizing social engagement. However, families should conduct a thorough walkthrough of the specific wing their loved one will occupy to assess the reported issues with facility odors.

Google Reviews

Google Reviews

51 reviews on Google
Oakwood Care and Rehabilitation is frequently praised for its friendly, welcoming staff and clean, well-appointed interior spaces. While many families express high satisfaction with the care provided to their loved ones, there are recurring reports of a persistent, strong odor of urine in the hallways. Families considering this facility should weigh the positive, compassionate staff culture against these specific environmental concerns.

Quality Themes

Tap a score for details
FoodN/AStaff9.0Clean6.0Activities8.0MedsN/AMemory8.0Comms9.0ValueN/A

Strengths

  • Friendly and welcoming staff
  • Clean and well-appointed interior
  • Helpful and attentive front desk
  • Strong sense of community and resident engagement

Concerns

  • Persistent, strong odor of urine in hallways (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.02024(10)4.92025(26)4.12026(10)

Distribution · 46 analyzed

5
39
4
5
3
0
2
1
1
1

How They Respond to Reviews

13%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1We've heard wonderful things about how welcoming and friendly the front desk and staff are; how do you foster that sense of community among the residents?
  • 2With the recent health inspections, what specific steps has the facility taken to address and resolve the identified deficiencies?
  • 3How does the housekeeping team manage cleanliness and air quality in the hallways to ensure a fresh environment for everyone?
  • 4Can you tell us more about the daily activities and social engagement programs available to keep residents active and involved?
  • 5What is the protocol for handling medical emergencies or urgent care needs during the overnight hours?
  • 6Since the staff is often described as very attentive, how do you ensure that care remains consistent even during shift changes?

Personalized based on this facility's data


Key Review Excerpts

The building is clean and the staff is friendly. It is an environment that feels inviting, the staff stop to welcome you and offer assistance and the residents are engaged in fun activities.

Visitor · 2024★★★★★

Mom has dementia, good and bad days, but the staff love her. I'm glad she's there for now.

Memory care family member · 2026★★★★★

The people at Oakwood were very, very nice, no complaints there. But the stench of urine was really bad, I have a good walk to get to my brother’s room and I smelled it really strong all the way down the halls.

Long-term resident's family · 2026★★★★
Source: 51 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.53hrs
71%
Registered nurses for medical care
Total Nursing
2.90hrs
71%
All nurses + aides combined
Staff Turnover
51%
Lower is better (< 30% = good)
RN Turnover
50%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

6

measures

Worse Than Avg

10

measures

Mixed Results

1

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility19.9%
Worse than Avg
Here
19.9%
US
12.1%
CO
8.5%
Jefferson
2.5%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility29.6%
Worse than Avg
Here
29.6%
US
14.4%
CO
13.8%
Jefferson
12.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility30.0%
Worse than Avg
Here
30.0%
US
19.4%
CO
21.7%
Jefferson
16.5%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility97.4%
Better than Avg
Here
97.4%
US
93.4%
CO
93.6%
Jefferson
84.7%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.0%
Better than Avg
Here
9.0%
US
19.5%
CO
11.3%
Jefferson
18.1%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility22.8%
Worse than Avg
Here
22.8%
US
15.3%
CO
14.4%
Jefferson
13.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility60.3%
Worse than Avg
Here
60.3%
US
81.8%
CO
76.3%
Jefferson
74.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility62.5%
Worse than Avg
Here
62.5%
US
79.8%
CO
75.6%
Jefferson
73.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility7.5%
Worse than Avg
Here
7.5%
US
1.6%
CO
1.5%
Jefferson
2.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

19deficiencies
5penalties
Well above state avg (8.8)
46 complaint-triggered
$235,923 in fines

Families have repeatedly filed complaints triggering 41 out of 115 deficiencies, with serious concerns about resident protection from abuse and neglect appearing across multiple surveys. Issues consistently involve neglect protection, infection control, and medication management, along with recurring problems with food safety and resident rights. While the facility corrects violations when cited, the pattern of repeated complaints about fundamental safety protections suggests ongoing challenges in maintaining consistent care standards.

Feb 26, 2026Complaint
6
0867Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0600Potential for harm · PatternCorrected

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.

0744Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0943Potential for harm · PatternCorrected

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.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Dec 18, 2025Complaint
4
0584Potential for harm · PatternCorrected

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.

0553Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

Sep 11, 2025Routine
18
0161Potential for harm · WidespreadCorrected

Construction Deficiencies

Use approved construction type or materials.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0291Potential for harm · WidespreadCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0355Potential for harm · WidespreadCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0541Potential for harm · WidespreadCorrected

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

0741Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0211Potential for harm · PatternCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0252Potential for harm · PatternCorrected

Egress Deficiencies

Provide at least two remote exits on each floor or fire section of the building.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0927Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0679Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0730Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

0947Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

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

Sep 11, 2025Complaint
2
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jun 12, 2025Complaint
3
0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Jan 29, 2025Complaint
6
0600Actual harm · IsolatedCorrected

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.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Federal Penalties

Fine

Jan 29, 2025

$53,151

Payment Denial

Jan 29, 2025

8-day denial

Fine

Apr 10, 2024

$52,416

Fine

Oct 9, 2023

$111,704

Payment Denial

Oct 9, 2023

21-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Oakwood Care and Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

342 facilities nationwide

Chain avg rating: 3.2/5 · Rank 314 of 328 (Worst)

Ownership & Management

Owners

Port, Barry

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Boyles, EddyManaging Control - Governing BodyGahm, GregoryManaging Control - Governing BodyJorgensen, DavidOfficer / DirectorBurnam, SoonOfficer / DirectorDunyon, DavidOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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