nursing home in Lakewood, CO
Lakewood Villa
1625 Simms St, Lakewood, CO 80215 · (303) 238-8161
★★★★★4
Above average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★3
- Staffing★★★★★3
- Quality measures★★★★★5
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Lakewood Villa at a glance
Lakewood Villa is a 57-bed for-profit nursing home in Lakewood, Colorado (Jefferson County).
CMS gives it 4 out of 5 stars on its overall star rating, better than the Colorado average of 3.2.
Residents receive about 3.1 hours of nursing care per day (0.6 of them from registered nurses), worse than the state average of 3.7 hours.
Its most recent standard health inspection (December 19, 2024) found 4 health citations. The Colorado average is 8.7.
Federal regulators fined it 1 time in the past three years, totaling $16,801.
Nursing staff turnover is 46.3% per year (state average 47.1%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Limited Liability Company
- Beds
- 57
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Madison Creek Partners
- Medicare-certified since
- June 1, 2013
- Resident/family council
- Resident
- County
- Jefferson County
- CMS Certification Number
- 065408
Ratings
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 4 / 5 | 3.2 / 5 | 3 / 5 | Better |
| Health inspection rating ⓘ (higher is better) | 3 / 5 | 2.7 / 5 | 2.8 / 5 | Average |
| Staffing rating ⓘ (higher is better) | 3 / 5 | 3.2 / 5 | 2.9 / 5 | Average |
| Quality measures rating ⓘ (higher is better) | 5 / 5 | 4.1 / 5 | 3.6 / 5 | Better |
| Long-stay quality rating (higher is better) | 5 / 5 | 4.1 / 5 | 3.8 / 5 | Better |
Staffing
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.10 hrs | 3.72 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 0.62 hrs | 0.82 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 2.01 hrs | 2.21 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 2.91 hrs | 3.29 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 46.3% | 47.1% | 45.8% | Average |
| Registered nurse turnover (yearly) (lower is better) | 63.6% | 44.6% | 42.9% | Worse |
| Administrators who left in the past year (lower is better) | 0 | 0 | 1 | Better |
Inspections
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 4 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 1 | 2 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 57 | 74 | 80.6 | Better |
Penalties
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 1 | 1 | 1 | Worse |
| Total fines in the past 3 years (lower is better) | $16,801 | $22,802 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 1 | 1 | 1 | Average |
Size
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 57 | 94 | 107 | |
| Average residents per day | 54 | 75 | 86 | |
| Occupancy | 94.6% | 80.7% | 80.9% |
Long-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 1.9% | 3.4% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 0% | 3.4% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 64.8% | 20% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 0% | 1.4% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0% | 0.6% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 16.7% | 13.4% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 10.1% | 13.3% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 6.3% | 4.7% | 5.2% | Worse |
| Long-stay residents with depressive symptoms (lower is better) | 0% | 8.8% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 8.7% | 11.5% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 20.8% | 21.2% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 75% | 94.7% | 95.5% | Worse |
| Long-stay residents given a pneumonia vaccine (higher is better) | 38.8% | 93.5% | 93.6% | Worse |
Short-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents given a pneumonia vaccine (higher is better) | 5.6% | 76.4% | 82% | Worse |
Inspection citations
State inspectors cited this home for 21 health deficiencies and 21 fire safety deficiencies in the inspection records CMS currently publishes. 5 citations involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 7, 2025 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected July 27, 2025 |
| March 25, 2025 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected April 25, 2025 |
| December 19, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | F Potential harm, widespread | Corrected April 12, 2025 |
| December 19, 2024 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected January 24, 2025 |
| December 19, 2024 Fire safety | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Tag K0511 | F Potential harm, widespread | Corrected January 30, 2025 |
| December 19, 2024 Fire safety | Have exits that are accessible at all times. Egress Deficiencies · Tag K0271 | F Potential harm, widespread | Corrected January 31, 2025 |
| December 19, 2024 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected January 13, 2025 |
| December 19, 2024 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | E Potential harm, pattern | Corrected February 7, 2025 |
| December 19, 2024 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | E Potential harm, pattern | Corrected February 23, 2025 |
| December 19, 2024 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | E Potential harm, pattern | Corrected January 24, 2025 |
| December 19, 2024 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | E Potential harm, pattern | Corrected February 5, 2025 |
| December 19, 2024 Fire safety | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Tag K0741 | D Potential harm, isolated | Corrected January 23, 2025 |
| December 19, 2024 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected January 17, 2025 |
| December 19, 2024 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected January 17, 2025 |
| December 19, 2024 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected January 17, 2025 |
| December 19, 2024 Standard | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected January 17, 2025 |
| December 19, 2024 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | D Potential harm, isolated | Corrected January 17, 2025 |
| May 1, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | J Immediate jeopardy, isolated | Corrected February 7, 2024 |
| January 25, 2024 Complaint | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Tag F0925 | F Potential harm, widespread | Corrected February 21, 2024 |
| January 25, 2024 Complaint | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Tag F0921 | E Potential harm, pattern | Corrected February 19, 2024 |
| July 17, 2023 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | F Potential harm, widespread | Corrected October 3, 2023 |
| July 17, 2023 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | F Potential harm, widespread | Corrected October 3, 2023 |
| July 17, 2023 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected October 3, 2023 |
| July 17, 2023 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | D Potential harm, isolated | Corrected October 3, 2023 |
| July 17, 2023 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | D Potential harm, isolated | Corrected October 3, 2023 |
| July 17, 2023 Fire safety | Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0911 | D Potential harm, isolated | Corrected October 3, 2023 |
| July 17, 2023 Standard | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Tag F0692 | G Actual harm, isolated | Corrected August 9, 2023 |
| July 17, 2023 Standard | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | G Actual harm, isolated | Corrected August 9, 2023 |
| July 17, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected August 9, 2023 |
| July 17, 2023 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected August 9, 2023 |
| July 17, 2023 Standard | 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. Pharmacy Service Deficiencies · Tag F0758 | D Potential harm, isolated | Corrected August 9, 2023 |
| July 17, 2023 Standard | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected August 9, 2023 |
| July 17, 2023 Standard | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Tag F0553 | D Potential harm, isolated | Corrected August 9, 2023 |
| October 31, 2019 Fire safety | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Tag K0521 | F Potential harm, widespread | Corrected November 27, 2019 |
| October 31, 2019 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | F Potential harm, widespread | Corrected November 27, 2019 |
| October 31, 2019 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | F Potential harm, widespread | Corrected December 3, 2019 |
| October 31, 2019 Fire safety | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Tag K0291 | D Potential harm, isolated | Corrected December 2, 2019 |
| October 31, 2019 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | D Potential harm, isolated | Corrected November 27, 2019 |
| October 31, 2019 Standard | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Tag F0744 | G Actual harm, isolated | Corrected December 2, 2019 |
| October 31, 2019 Standard | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | G Actual harm, isolated | Corrected November 22, 2019 |
| October 31, 2019 Standard | Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · Tag F0923 | E Potential harm, pattern | Corrected November 10, 2019 |
| October 31, 2019 Standard | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Tag F0625 | D Potential harm, isolated | Corrected November 15, 2019 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports 1 federal penalty in the past three years, including $16,801 in fines.
| Date | Penalty | Amount / length |
|---|---|---|
| May 1, 2024 | Fine | $16,801 |
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| CHIEF JOSEPH TRAIL, LLC Organization | 5% or greater direct ownership interest | 100% | 03/02/2026 |
| CLEGG, MICHAEL Individual | 5% or greater indirect ownership interest | — | 03/02/2026 |
| TIPPET, LLC Organization | 5% or greater indirect ownership interest | — | 03/02/2026 |
| WHITE CANYON, LLC Organization | 5% or greater indirect ownership interest | — | 03/02/2026 |
| CHRISTENSEN, COVEY Individual | adp of the snf | NOT APPLICABLE | 06/01/2013 |
| CLEGG, MICHAEL Individual | adp of the snf | NOT APPLICABLE | 06/26/2023 |
| HOPKINS, AMBER Individual | adp of the snf | NOT APPLICABLE | 12/01/2021 |
| HOWE, ROBERT Individual | adp of the snf | NOT APPLICABLE | 06/01/2018 |
| IKERD, JOHN Individual | adp of the snf | NOT APPLICABLE | 04/25/2022 |
| JAMES, KENDRA Individual | adp of the snf | NOT APPLICABLE | 06/01/2023 |
| MADISON CREEK PARTNERS LLC Organization | adp of the snf | NOT APPLICABLE | 11/13/2025 |
| CLEGG, MICHAEL Individual | managing control - governing body | NOT APPLICABLE | 06/26/2023 |
| IKERD, JOHN Individual | managing control - governing body | NOT APPLICABLE | 03/02/2026 |
| CHRISTENSEN, COVEY Individual | operational/managerial control | NOT APPLICABLE | 06/01/2013 |
| CLEGG, MICHAEL Individual | operational/managerial control | NOT APPLICABLE | 06/26/2023 |
| HOPKINS, AMBER Individual | operational/managerial control | NOT APPLICABLE | 12/01/2021 |
| HOWE, ROBERT Individual | operational/managerial control | NOT APPLICABLE | 06/01/2018 |
| IKERD, JOHN Individual | operational/managerial control | NOT APPLICABLE | 04/25/2022 |
| JAMES, KENDRA Individual | operational/managerial control | NOT APPLICABLE | 06/01/2023 |
| MADISON CREEK PARTNERS LLC Organization | operational/managerial control | NOT APPLICABLE | 06/01/2013 |
Other nursing homes near Lakewood Villa
Ahc of Lakewood, LLC
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★★★★★5Much above averageAllison Care Center
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- Abuse citation
★★★★★2Below averageWestern Hills Health Care Center
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★★★★★3AverageHarmony Pointe Care Center
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★★★★★3AverageMountain Vista Health Center
4800 Tabor St, Wheat Ridge, CO 80033 · 2.9 mi
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★★★★★2Below averageLakeside Post Acute
6270 W 38th Ave, Wheat Ridge, CO 80033 · 3.7 mi
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- Abuse citation
★★★★★3Average
Frequently asked questions
What is Lakewood Villa's rating?
Lakewood Villa has 4 out of 5 stars on the CMS overall star rating. The average for Colorado nursing homes is 3.2 stars.
How many inspection citations did Lakewood Villa receive?
Its most recent standard health inspection found 4 citations, compared with a Colorado average of 8.7. Every citation is listed on this page with its severity.
Does Lakewood Villa accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Lakewood Villa?
It is for profit - limited liability company and part of Madison Creek Partners. The ownership section on this page lists the owners and managers reported to CMS.
Where is Lakewood Villa and how do I contact it?
Lakewood Villa is at 1625 Simms St, Lakewood, CO 80215. Phone: (303) 238-8161.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.