01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-12-19 | 4 | 2024-12-19 | 10 |
| Cycle 2 | 2023-07-17 | 10 | 2023-07-17 | 6 |
| Cycle 3 | 2019-10-31 | 7 | 2019-10-31 | 5 |
CMS CCN 0654082026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lakewood Villa
1625 Simms St · Lakewood, CO 80215 · Jefferson County
Certified beds57CMS provider file
Recent citation rows42current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
42 rows in the current release
5 rows carry G–L scope/severity codes; 1 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-07-07 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-07-27 · complaint2025-03-25 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-04-25 · complaint2024-12-19 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-01-17 · complaint2024-12-19 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-12-19 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-01-17 · complaint2024-12-19 · FIREK0271Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2025-01-312024-12-19 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-01-132024-12-19 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Waiver has been granted · 2025-02-232024-12-19 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Waiver has been granted · 2025-04-122024-12-19 · FIREK0355Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-01-242024-12-19 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-02-072024-12-19 · FIREK0511Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-01-302024-12-19 · FIREK0521Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-19 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-01-242024-12-19 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-01-232024-05-01 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2024-02-07 · complaint2024-01-25 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-02-19 · complaint2024-01-25 · HEALTHF0925Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2024-02-21 · complaint2023-07-17 · HEALTHF0553Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Correction field: Deficient, Provider has date of correction · 2023-08-092023-07-17 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2023-08-092023-07-17 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-08-092023-07-17 · HEALTHF0692Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2023-08-0903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-05-01 | Fine | $16,801 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHIEF JOSEPH TRAIL, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/02/2026
- TIPPET, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- WHITE CANYON, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- CLEGG, MICHAELIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/02/2026
- CLEGG, MICHAELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/26/2023
- IKERD, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 03/02/2026
- MADISON CREEK PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2013
- CHRISTENSEN, COVEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2013
- CLEGG, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/26/2023
- HOPKINS, AMBERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- HOWE, ROBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2018
- IKERD, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/25/2022
- JAMES, KENDRAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2023
- MADISON CREEK PARTNERS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/13/2025
- CHRISTENSEN, COVEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/01/2013
- CLEGG, MICHAELIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/26/2023
- HOPKINS, AMBERIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2021
- HOWE, ROBERTIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/01/2018
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.10per resident day
RN hours0.62per resident day
Weekend nurse hours2.91per resident day
Staff turnover46.3%CMS reported field
06 / LOCAL RECORDS
Open the Lakewood ledger →Other published facilities nearby
Ahc Of Lakewood, Llc36 beds · CMS overall 5/524 citation rowsAllison Care Center85 beds · CMS overall 2/525 citation rowsCambridge Care Center110 beds · CMS overall 3/541 citation rowsCedars Healthcare Center130 beds · CMS overall 3/570 citation rowsEdgewater Health And Rehabilitation67 beds · CMS overall 5/529 citation rowsHarmony Pointe Care Center125 beds · CMS overall 3/557 citation rowsLakewood Post Acute And Rehabilitation108 beds · CMS overall 3/556 citation rowsMapleton Post Acute90 beds · CMS overall 4/561 citation rows