Lakewood Villa — nursing home in Lakewood, CO

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 57 CMS-certified beds (not state-licensed beds)
Licensed beds: State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead.
Average residents per day: 54.4 CMS, MDS-derived
CMS Certification Number: 065408
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): Jun 1, 2013
Ownership type: For profit - Limited Liability company
Operator (legal business name): Lakewood Villa Operations, LLC
CMS chain: Madison Creek Partners 13 facilities
Phone: (303) 238-8161
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

10

latest Jul 7, 2025

Citations

42

21 health · 21 fire

Harm or worse

5

1 immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J1	K·	L·
Actual harm	G4	H·	I·
Potential harm	D15	E8	F14
Minimal	A·	B·	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

1

$16,801

Payment denials

0

Latest

May 1, 2024

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 065408
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 57
First approved: Jun 1, 2013
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 1, 2026
Evidence: Verified

State license

State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead. State coverage for Colorado.

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Jul 7, 2025	Health	Health Complaint	1	Potential harm	—	Open →
Mar 25, 2025	Health	Health Complaint	1	Potential harm	—	Open →
Dec 19, 2024	Fire safety	Fire Safety Standard	10	Potential harm	—	Open →
Dec 19, 2024	Health	Health Complaint, Health Standard	5	Potential harm	—	Open →
May 1, 2024	Health	Health Complaint	1	Immediate jeopardy	—	Open →
Jan 25, 2024	Health	Health Complaint	2	Potential harm	—	Open →
Jul 17, 2023	Fire safety	Fire Safety Standard	6	Potential harm	—	Open →
Jul 17, 2023	Health	Health Standard	7	Actual harm	—	Open →
Oct 31, 2019	Fire safety	Fire Safety Standard	5	Potential harm	—	Open →
Oct 31, 2019	Health	Health Standard	4	Actual harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

Date	Type	Amount	Payment denial	Record
May 1, 2024	Civil money penalty (fine)	$16,801	—	065408\|Fine\|115843

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J1	K·	L·
Actual harm	G4	H·	I·
Potential harm	D15	E8	F14
Minimal	A·	B·	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction	Flags
Jul 7, 2025	F-0600	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 · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jul 27, 2025	Complaint
Mar 25, 2025	F-0600	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 · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Apr 25, 2025	Complaint
Dec 19, 2024	K-0271	Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jan 31, 2025
Dec 19, 2024	K-0291	Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jan 13, 2025
Dec 19, 2024	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Waiver granted Feb 23, 2025
Dec 19, 2024	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Waiver granted Apr 12, 2025
Dec 19, 2024	K-0355	Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jan 24, 2025
Dec 19, 2024	K-0363	Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Feb 7, 2025
Dec 19, 2024	K-0511	Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jan 30, 2025
Dec 19, 2024	K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Feb 5, 2025
Dec 19, 2024	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jan 24, 2025
Dec 19, 2024	K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jan 23, 2025
Dec 19, 2024	F-0600	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 · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jan 17, 2025	Complaint
Dec 19, 2024	F-0759	Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Jan 17, 2025
Dec 19, 2024	F-0760	Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Jan 17, 2025
Dec 19, 2024	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Jan 17, 2025
Dec 19, 2024	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	E · Potential harm Pattern	Corrected Jan 17, 2025	Complaint
May 1, 2024	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	J · Immediate jeopardy Isolated	Past non-compliance Feb 7, 2024	Complaint
Jan 25, 2024	F-0921	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Feb 19, 2024	Complaint
Jan 25, 2024	F-0925	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Feb 21, 2024	Complaint
Jul 17, 2023	F-0689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care	G · Actual harm Isolated	Corrected Aug 9, 2023
Jul 17, 2023	F-0692	Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care	G · Actual harm Isolated	Corrected Aug 9, 2023
Jul 17, 2023	K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 3, 2023
Jul 17, 2023	K-0291	Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 3, 2023
Jul 17, 2023	K-0363	Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 3, 2023
Jul 17, 2023	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 3, 2023
Jul 17, 2023	K-0911	Meet requirements for the installation and maintenance of electrical systems. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Oct 3, 2023
Jul 17, 2023	K-0918	Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Oct 3, 2023
Jul 17, 2023	F-0553	Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Aug 9, 2023
Jul 17, 2023	F-0600	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 · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Aug 9, 2023
Jul 17, 2023	F-0758	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 · Medication management	D · Potential harm Isolated	Corrected Aug 9, 2023
Jul 17, 2023	F-0761	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 · Medication management	E · Potential harm Pattern	Corrected Aug 9, 2023
Jul 17, 2023	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	F · Potential harm Widespread	Corrected Aug 9, 2023
Oct 31, 2019	F-0600	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 · Resident rights & abuse/neglect	G · Actual harm Isolated	Corrected Nov 22, 2019
Oct 31, 2019	F-0744	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care	G · Actual harm Isolated	Corrected Dec 2, 2019
Oct 31, 2019	K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Dec 3, 2019
Oct 31, 2019	K-0291	Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Dec 2, 2019
Oct 31, 2019	K-0345	Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 27, 2019
Oct 31, 2019	K-0363	Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Nov 27, 2019
Oct 31, 2019	K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Services Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Nov 27, 2019
Oct 31, 2019	F-0625	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 · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Nov 15, 2019
Oct 31, 2019	F-0923	Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Nov 10, 2019

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.1

Health inspectionsstate 2.7

Staffingstate 3.1

Quality measuresstate 4.2

Long-stay QM

Short-stay QMNot rated

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing3.05

State avg 3.69US avg 3.90

Registered nurse (RN)0.66

State avg 0.81US avg 0.69

Licensed practical nurse0.42

State avg 0.68US avg 0.86

Nurse aide1.98

State avg 2.20US avg 2.35

Weekend total nurse2.90

State avg 3.26US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.47 (case-mix index 1.23).

Staff turnover

Total nursing staff turnover40.5%

State avg 47.0%US avg 45.3%

Registered nurse turnover55.6%

State avg 44.4%US avg 42.5%

Administrators who left1

State avg 1US avg 1

Health survey score

Cycle 1 standard survey: Dec 19, 2024
Cycle 1 health score: 32
Total weighted score: 57

Operating entity

Lakewood Villa Operations, LLC

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

Madison Creek Partners

13 facilities in 2 states. CMS chain ID 328.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 3.2

Ownership disclosures

Disclosures

20

Organizations

4

Individuals

15

Direct & indirect ownership

Owners of record

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Chief Joseph Trail, LLC	Organization	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	100%	Mar 2, 2026
Tippet, LLC	Organization	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026
White Canyon, LLC	Organization	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026
Michael Clegg	Individual	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Chief Joseph Trail, LLC	Organization	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	100%	Mar 2, 2026
Tippet, LLC	Organization	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026
White Canyon, LLC	Organization	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026
Michael Clegg	Individual	Indirect owner	5% OR GREATER INDIRECT OWNERSHIP INTEREST	not provided	Mar 2, 2026
Michael Clegg	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Jun 26, 2023
John Ikerd	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Mar 2, 2026
Madison Creek Partners LLC	Organization	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Jun 1, 2013
Covey Christensen	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Jun 1, 2013
Michael Clegg	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Jun 26, 2023
Amber Hopkins	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Dec 1, 2021
Robert Howe	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Jun 1, 2018
John Ikerd	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Apr 25, 2022
Kendra James	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Jun 1, 2023
Madison Creek Partners LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Nov 13, 2025
Covey Christensen	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jun 1, 2013
Michael Clegg	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jun 26, 2023
Amber Hopkins	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Dec 1, 2021
Robert Howe	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jun 1, 2018
John Ikerd	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Apr 25, 2022
Kendra James	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jun 1, 2023

Same chain in Colorado

All 12 in chain →

Facility	Beds	Last inspection	Citations (window)	Fines
Sundance Skilled Nursing and Rehabilitation 2612 W Cucharras St, Colorado Springs, CO 80904 CCN 065152	68	Feb 26, 2026	481 IJ	$15k
Pueblo Heights Nursing and Rehabilitation 1601 Constitution Rd, Pueblo, CO 81001 CCN 065169	120	Apr 14, 2026	391 IJ	$20k
The Gardens 104 Lois Ln, Colorado Springs, CO 80904 CCN 065198	45	Dec 11, 2025	215 open	—
Pioneer Health Care Center 900 S 12th St, Rocky Ford, CO 81067 CCN 065235	101	Mar 4, 2025	534 harm	$10k
Glenwood Springs Healthcare 2305 Blake Ave, Glenwood Springs, CO 81601 CCN 065244	54	Apr 21, 2026	582 harm	—
Paonia Care and Rehabilitation Center 1625 Meadowbrook Blvd, Paonia, CO 81428 CCN 065251Abuse icon	60	Jul 14, 2026	691 IJ5 harm4 open	$33k
Silver Heights Skilled Nursing and Rehabilitation 4001 Home St, Castle Rock, CO 80108 CCN 065285	91	Apr 3, 2025	58	—

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 1625 Simms St, Lakewood, CO 80215
ZIP: 80215
County: Jefferson County FIPS 08059
State: Colorado
Urban / rural (CMS): Urban

Within ~25 km

Nearby nursing homes

Facility	Distance	Beds	Last inspection	Citations (window)	Fines
Ahc of Lakewood, LLC 11155 W 15th Pl, Lakewood, CO 80215 CCN 065435	0.9 km	36	Mar 19, 2026	24	$18k
Allison Care Center 1660 Allison St, Lakewood, CO 80214 CCN 065297Abuse icon	3.4 km	85	Jun 11, 2026	253 harm	$35k
Western Hills Health Care Center 1625 Carr St, Lakewood, CO 80214 CCN 065209	3.4 km	140	Aug 19, 2026	181 harm1 open	—
Harmony Pointe Care Center 1655 Yarrow St, Lakewood, CO 80214 CCN 065298	4.3 km	125	Sep 26, 2024	573 harm	—
Grandview Health and Rehab LLC 4800 Tabor St, Wheat Ridge, CO 80033 CCN 065015	4.7 km	168	Apr 30, 2026	693 harm1 open	$39k
Lakeside Post Acute 6270 W 38th Ave, Wheat Ridge, CO 80033 CCN 065273	5.9 km	78	Jun 25, 2026	591 IJ1 harm6 open	$14k
Cedars Healthcare Center 1599 Ingalls St, Lakewood, CO 80214 CCN 065202	6 km	130	Jun 11, 2026	582 IJ2 open	$16k
Edgewater Health and Rehabilitation 1655 Eaton St, Lakewood, CO 80214 CCN 065171	6 km	67	Aug 27, 2025	291 harm	—

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	065408	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	065408	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026

Record-level source links for CCN 065408

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction