Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
OAKWOOD CARE AND REHABILITATION
LAKEWOOD, CO · 170 certified beds · Last Life Safety survey September 11, 2025
CMS Certification Number 065248 · first certified March 1989
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
- Ownership changed March 1, 2024 (change of ownership)from BETHANY NURSING & REHAB CENTER LLC
Position within CO
46 citations — more than 100% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 16. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was September 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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9 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 46 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 46 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 46 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 17, 2022 | 20 |
| April 10, 2024 | 12 |
| September 11, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-09-11 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-09-11 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-09-11 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 3 | 2025-09-11 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-09-11 |
| K-0541 | Install properly constructed and protected linen or trash chutes. | 2 | 2025-09-11 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-04-10 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-04-10 |
What the citations cover
- Smoke Deficiencies 18
- Egress Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Emergency Preparedness Deficiencies 5
- Other 8
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Egress Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 5 |
| Services Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 11, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has plan of correction |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0222 | 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. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Deficient, Provider has plan of correction |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (January 31, 2026) |
April 10, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0231 | Provide large enough exits. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (July 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (July 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (June 28, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (June 28, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 1, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (July 28, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 1, 2024) |
November 17, 2022 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 17, 2022) |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 17, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (December 17, 2022) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (December 17, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (December 17, 2022) |
| K-0222 | 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. | Waiver has been granted (March 31, 2023) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Waiver has been granted (March 31, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (March 31, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Waiver has been granted (March 31, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (March 31, 2023) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | Waiver has been granted (March 31, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (March 31, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 30, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.