Colorado › Jefferson County › Lakewood
Lakewood Villa
1625 Simms St, Lakewood, CO 80215
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Lakewood Villa, in Lakewood, Colorado, is certified for 57 beds under for-profit, limited liability company ownership and belongs to the Madison Creek Partners chain.
CMS gives it 4 of 5 stars overall, above the Colorado median of 3; the health inspection rating is 3, staffing 3 and quality measures 5.
Inspectors recorded 21 health deficiencies across the three most recent survey cycles (4, 10, 7 by cycle, most recent first), 5 of them at the actual-harm or immediate-jeopardy level. That is 36.8 per 100 beds, more than the state median of 25.0.
CMS lists 1 penalty in the period covered: fines totalling $17K.
Reported nurse staffing is 3.1 hours per resident per day (0.6 RN), close to the Colorado median of 3.5; nursing staff turnover is 46.3%.
Compared with county, state and nation
| Measure | This facility | Jefferson Co. median | Colorado median | US average |
|---|---|---|---|---|
| Overall star rating | 4 | 3 | 3 | 3.0 |
| Health citations, 3 cycles | 21 | 21 | 22 | 28.7 |
| Citations per 100 beds | 36.8 | 27.8 | 25.0 | 26.8 |
| Total nurse hours per resident day | 3.1 | 3.5 | 3.5 | 3.9 |
| RN hours per resident day | 0.6 | 0.7 | 0.7 | 0.7 |
| Nursing staff turnover | 46.3% | 46.8% | 46.7% | 45.8% |
| Fines listed | $16,801 | $16,801 | $10,033 | — |
County and state figures are medians across facilities (23 in the county, 210 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Colorado average per facility for the same cycle, as published by CMS. Standard health survey dates: 19 Dec 2024, 17 Jul 2023.
Severity mix: J ×1 G ×4 D ×9 E ×4 F ×3
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 7 Jul 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 27 Jul 2025 |
| 25 Mar 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 25 Apr 2025 |
| 19 Dec 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 17 Jan 2025 |
| 19 Dec 2024 | F0880 | Provide and implement an infection prevention and control program. | E | Complaint investigation | 17 Jan 2025 |
| 19 Dec 2024 | F0759 | Ensure medication error rates are not 5 percent or greater. | D | Standard survey | 17 Jan 2025 |
| 19 Dec 2024 | F0760 | Ensure that residents are free from significant medication errors. | D | Standard survey | 17 Jan 2025 |
| 19 Dec 2024 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Complaint investigation | 17 Jan 2025 |
| 1 May 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint investigation | 7 Feb 2024 |
| 25 Jan 2024 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F | Complaint investigation | 21 Feb 2024 |
| 25 Jan 2024 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Complaint investigation | 19 Feb 2024 |
| 17 Jul 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0692 | Provide enough food/fluids to maintain a resident's health. | G | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0761 | 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. | E | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. | D | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Standard survey | 9 Aug 2023 |
| 17 Jul 2023 | F0758 | 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. | D | Standard survey | 9 Aug 2023 |
| 31 Oct 2019 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Standard survey | 22 Nov 2019 |
| 31 Oct 2019 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | G | Standard survey | 2 Dec 2019 |
| 31 Oct 2019 | F0923 | Have enough outside ventilation via a window or mechanical ventilation, or both. | E | Standard survey | 10 Nov 2019 |
| 31 Oct 2019 | F0625 | 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. | D | Standard survey | 15 Nov 2019 |
Penalties
| Date | Type | Amount | Detail |
|---|---|---|---|
| 1 May 2024 | Fine | $16,801 |
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Colorado average. Turnover: nursing staff 46.3%, RNs 63.6%; 0 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Colorado median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 16.7% | 11.1% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | 0.0% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | 0.9% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 1.9% | 3.0% | 2.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 10.1% | 11.9% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.0% | 3.0% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 64.8% | 18.8% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, limited liability company. Legal business name: Lakewood Villa Operations, Llc. Chain: Madison Creek Partners (13 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Chief Joseph Trail, LLC | 5% or greater direct ownership interest | 100% | 03/02/2026 |
| Tippet, LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 03/02/2026 |
| White Canyon, LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 03/02/2026 |
| Madison Creek Partners LLC | Operational/managerial control | NOT APPLICABLE | 06/01/2013 |
| Madison Creek Partners LLC | Adp of the snf | NOT APPLICABLE | 11/13/2025 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Jefferson County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Ahc of Lakewood, LLC | Lakewood | 36 | 5 | 5 | 3 | 10 | 27.8 | $54K | 19 Mar 2026 |
| Arvada Care and Rehabilitation Center | Arvada | 54 | 5 | 4 | 3 | 17 | 31.5 | $8K | 15 Jan 2026 |
| Edgewater Health and Rehabilitation | Lakewood | 67 | 5 | 4 | 4 | 12 | 17.9 | — | 27 Aug 2025 |
| Life Care Center of Evergreen | Evergreen | 120 | 4 | 4 | 4 | 11 | 9.2 | — | 15 May 2025 |
| Mapleton Post Acute | Lakewood | 90 | 4 | 3 | 2 | 28 | 31.1 | — | 17 Jun 2025 |
| Neurorestorative Colorado | Littleton | 36 | 4 | 3 | 4 | 13 | 36.1 | $13K | 1 May 2025 |
| Rehabilitation Center At Sandalwood, The | Wheat Ridge | 103 | 4 | 3 | 4 | 23 | 22.3 | $46K | 11 Feb 2026 |
| Villa Manor Care Center | Lakewood | 110 | 4 | 3 | 4 | 28 | 25.5 | — | 26 Mar 2026 |
All 23 facilities in Jefferson County
Questions and answers
How many deficiencies has Lakewood Villa been cited for?
21 health deficiencies across the three most recent survey cycles, 5 at the actual-harm or immediate-jeopardy level. The Colorado median is 22 per facility.
Has Lakewood Villa been fined?
Yes. CMS lists fines totalling $17K in the period covered.
How does staffing at Lakewood Villa compare?
Reported total nurse staffing is 3.1 hours per resident per day against a Colorado median of 3.5 and a national average of 3.9.
Who operates Lakewood Villa?
It is part of the Madison Creek Partners chain. Ownership type is for-profit, limited liability company. Organisations in the CMS ownership record include Chief Joseph Trail, LLC, Tippet, LLC and White Canyon, LLC. Individual owners and managers are not listed on this site.
When was Lakewood Villa last inspected?
The most recent survey or investigation in the CMS record is dated 7 Jul 2025; the most recent standard health survey was 19 Dec 2024.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.