Lakewood Villa
1625 Simms St, Lakewood, CO 80215 · Jefferson County · 57 certified beds · avg 54 residents/day · certified since Jun 1, 2013 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: MADISON CREEK PARTNERS (13 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 1, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 7, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jul 17, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 9, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 17, 2023 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 9, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 31, 2019 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 22, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 31, 2019 · F-0744
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 2, 2019 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 7, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 25, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 19, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 19, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Dec 19, 2024 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 1, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 25, 2024 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jul 17, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 17, 2023 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 17, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 17, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 17, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Oct 31, 2019 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 31, 2019 | ▲ G · Actual harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Oct 31, 2019 | E · Potential for harm, repeated | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. |
| Oct 31, 2019 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (7 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 4 | 2 | G ▲ |
| 2023 | 7 | 2 | G ▲ |
| 2024 | 8 | 1 | J ▲ |
| 2025 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $16,801.
| Date | Type | Amount / length |
|---|---|---|
| May 1, 2024 | Fine | $16,801 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.43 | 3.89 | 3.95 | bottom 32% in Colorado; bottom 33% in the U.S. |
| Registered Nurse hours | 0.68 | 0.86 | 0.69 | bottom 35% in Colorado; top 38% in the U.S. |
| Weekend total nurse staffing | 3.21 | 3.44 | 3.50 | bottom 44% in Colorado; bottom 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.51 | 0.61 | 0.48 | bottom 45% in Colorado; top 32% in the U.S. |
| Total nursing staff turnover (%) | 46.3 | 47.1 | 45.8 | top 49% in Colorado; bottom 46% in the U.S. |
| RN turnover (%) | 63.6 | 44.6 | 42.9 | bottom 15% in Colorado; bottom 17% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.10, RN 0.62, weekend 2.91. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | 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 | Operational/Managerial Control | NOT APPLICABLE | 06/01/2013 |
| Christensen, Covey | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2013 |
| Clegg, Michael | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/26/2023 |
| Clegg, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 06/26/2023 |
| Hopkins, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2021 |
| Hopkins, Amber | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2021 |
| Howe, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2018 |
| Howe, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2018 |
| Ikerd, John | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/02/2026 |
| Ikerd, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/25/2022 |
| Ikerd, John | Individual | ADP of the SNF | NOT APPLICABLE | 04/25/2022 |
| James, Kendra | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2023 |
| James, Kendra | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Madison Creek Partners LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2013 |
| Madison Creek Partners LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/13/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ahc of Lakewood, LLC | 0.5 mi | Lakewood, CO | ★★★★★ | 5/5 | |
| Western Hills Health Care Center | 2.1 mi | Lakewood, CO | ★★★☆☆ | 3/5 | |
| Allison Care Center | 2.1 mi | Lakewood, CO | ★★☆☆☆ | 2/5 | abuse |
| Harmony Pointe Care Center | 2.7 mi | Lakewood, CO | ★★★☆☆ | 2/5 | |
| Mountain Vista Health Center | 2.9 mi | Wheat Ridge, CO | ★★☆☆☆ | 2/5 | |
| Lakeside Post Acute | 3.7 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 | abuse |
| Edgewater Health and Rehabilitation | 3.7 mi | Lakewood, CO | ★★★★★ | 4/5 | |
| Cedars Healthcare Center | 3.7 mi | Lakewood, CO | ★★★☆☆ | 2/5 | |
| Cambridge Care Center | 3.7 mi | Lakewood, CO | ★★★☆☆ | 2/5 | abuse |
| Sierra Post Acute | 3.7 mi | Lakewood, CO | ★★☆☆☆ | 1/5 | abuse |
| Villa Manor Care Center | 3.8 mi | Lakewood, CO | ★★★★☆ | 3/5 | |
| Wheatridge Care Center | 3.9 mi | Wheat Ridge, CO | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065408.