Nursing homeActive
Lakewood Villa
1625 Simms St, Lakewood, CO 80215303238816157 certified beds · 54 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
7
since 2019
Deficiencies
21
● 0● 16● 5
Penalties · 3 yrs
$16,801
1 fine
Last survey
2025-07-07
Complaint
CMS overall
4 / 5
stars as published by CMS
CMS overall 4/5
Health 3
Staffing 3
Quality 5
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Colorado Department of Public Health & Environment · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-07-07 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-03-25 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-12-19 | Standard | 050 | CMS-2567 (Care Compare) | — |
| 2024-05-01 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-01-25 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-07-17 | Standard | 052 | CMS-2567 (Care Compare) | — |
| 2019-10-31 | Standard | 022 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Colorado Department of Public Health & Environment publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-27Record 065408-20250707-F600
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-04-25Record 065408-20250325-F600
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 065408-20241219-F600
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 065408-20241219-F759
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 065408-20241219-F760
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 065408-20241219-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 065408-20241219-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-02-07Record 065408-20240501-F689
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-02-19Record 065408-20240125-F921
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-02-21Record 065408-20240125-F925
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-08-09Record 065408-20230717-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-08-09Record 065408-20230717-F692
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-09Record 065408-20230717-F553
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-09Record 065408-20230717-F600
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-09Record 065408-20230717-F758
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-09Record 065408-20230717-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-08-09Record 065408-20230717-F812
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2019-11-22Record 065408-20191031-F600
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2019-12-02Record 065408-20191031-F744
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-11-15Record 065408-20191031-F625
F923Have enough outside ventilation via a window or mechanical ventilation, or both.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-11-10Record 065408-20191031-F923
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-05-01 | Civil money penalty | $16,801 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.62
Facility
Colorado
National
Colorado 0.82 · National 0.69
Total nurse hours per resident day3.10
Facility
Colorado
National
Colorado 3.72 · National 3.86
Weekend total nurse hours2.91
Facility
Colorado
National
Colorado 3.30 · National 3.42
Total nursing staff turnover46%
Facility
Colorado
National
Colorado 47% · National 46%
Registered nurse turnover64%
Facility
Colorado
National
Colorado 45% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Colorado | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 0.0% | 3.4% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.9% | 3.4% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 64.8% | 20.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 1.4% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 16.7% | 13.4% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 6.3% | 4.7% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 8.7% | 11.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Chief Joseph Trail, LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Clegg, Michael Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Tippet, LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| White Canyon, LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Christensen, Covey Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Clegg, Michael Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hopkins, Amber Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Howe, Robert Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Ikerd, John Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| James, Kendra Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Madison Creek Partners LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Christensen, Covey Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Clegg, Michael Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Clegg, Michael Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Hopkins, Amber Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Howe, Robert Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ikerd, John Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Ikerd, John Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| James, Kendra Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Madison Creek Partners LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Madison Creek Partners — 13 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Colorado.
No county cost figures on file for Jefferson.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Ahc Of Lakewood, LLC Lakewood | 0.5 mi | 2026-03-19 | 0100 |
| Allison Care Center Lakewood | 2.1 mi | 2026-06-11 | 053 |
| Western Hills Health Care Center Lakewood | 2.1 mi | 2026-05-14 | 0150 |
| Mountain Vista Health Center Wheat Ridge | 2.9 mi | 2026-04-30 | 0273 |
| Harmony Pointe Care Center Lakewood | 2.7 mi | 2024-09-26 | 0170 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |