Lakewood Villa

Nursing Home · Lakewood, CO

CMS overall rating 4/5 For profit - Limited Liability company

CMS certification number065408

Contact & location

1625 Simms ST
Lakewood, CO 80215
Jefferson County
Phone
(303) 238-8161
ZIP code
80215 – all care providers

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Facility details

Certified beds
57
Residents per day
53.9 (95% occupied)
Ownership
For profit - Limited Liability company
Legal name
Lakewood Villa Operations, LLC
Chain
Madison Creek Partners (13 facilities, avg 3.2★)
Medicare certified since
June 1, 2013
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 4/5
State avg 3.1
Health inspections★★★★★ 3/5
State avg 2.7
Staffing★★★★★ 3/5
State avg 3.1
Quality measures★★★★★ 5/5
State avg 4.1
Long-stay quality★★★★★ 5/5
Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.10 (state 3.72 · U.S. 3.86)
Registered nurses (RN)
0.62 (state 0.82 · U.S. 0.69)
Licensed practical nurses
0.47 (state 0.68 · U.S. 0.86)
Nurse aides
2.01 (state 2.22 · U.S. 2.32)
Weekend total
2.91 (state 3.30 · U.S. 3.42)
Nursing staff turnover
46.3 (state 47.1 · U.S. 45.8)%
RN turnover
63.6 (state 44.6 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
December 19, 2024
Health deficiencies (last cycle)
4.0 (state 8.6 · U.S. 9.3)
From complaints
1
Citations on record (3 years)
21 health · 21 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2025-07-07 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-07-27
2025-03-25 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-25
2024-12-19 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-01-17
2024-12-19 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-01-17
2024-12-19 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-01-17
2024-12-19 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-01-17
2024-12-19 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-01-17
2024-05-01 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2024-02-07
2024-01-25 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F0925 · Environmental Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-02-21
2024-01-25 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-02-19
2023-07-17 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2023-08-09
2023-07-17 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2023-08-09
2023-07-17 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2023-08-09
2023-07-17 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2023-08-09
2023-07-17 Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F0553 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-09
2023-07-17 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-09
2023-07-17 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-09
2019-10-31 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 G
Actual harm		 Corrected 2019-11-22
2019-10-31 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F0744 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2019-12-02
2019-10-31 Have enough outside ventilation via a window or mechanical ventilation, or both.
F0923 · Environmental Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2019-11-10
2019-10-31 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.
F0625 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2019-11-15

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $16,801 in fines.

DateTypeAmount
2024-05-01Fine$16,801

Ownership & management

NameRoleSince
Chief Joseph Trail, LLC (organization)5%+ Direct Ownership Interest · 100%
Clegg, Michael (individual)5%+ Indirect Ownership Interest
Tippet, LLC (organization)5%+ Indirect Ownership Interest
White Canyon, LLC (organization)5%+ Indirect Ownership Interest
Christensen, Covey (individual)Administrator · NOT APPLICABLE
Clegg, Michael (individual)Administrator · NOT APPLICABLE
Hopkins, Amber (individual)Administrator · NOT APPLICABLE
Howe, Robert (individual)Administrator · NOT APPLICABLE
Ikerd, John (individual)Administrator · NOT APPLICABLE
James, Kendra (individual)Administrator · NOT APPLICABLE
Madison Creek Partners LLC (organization)Administrator · NOT APPLICABLE
Clegg, Michael (individual)Managing Control - Governing Body · NOT APPLICABLE
Ikerd, John (individual)Managing Control - Governing Body · NOT APPLICABLE
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

Frequently asked questions

What is the rating of Lakewood Villa?

Lakewood Villa has a 4-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.1-star average in Colorado.

How many beds does Lakewood Villa have?

It has 57 certified beds and cares for about 54 residents per day.

Has Lakewood Villa been fined?

Yes. CMS lists 1 penalty totaling $16,801 in the last three years.

Who owns Lakewood Villa?

It is part of Madison Creek Partners and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Lakewood Villa?

(303) 238-8161. The facility is located at 1625 Simms ST, Lakewood, CO 80215.

Other nursing homes in Lakewood

Compare all nursing homes in Lakewood, CO →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.