Lakewood Villa
Lakewood, Jefferson County, Colorado · CCN 065408 · For-profit (LLC) · part of Madison Creek Partners (13 facilities, chain average 3.2 stars)
CMS rates Lakewood Villa 4 of 5 overall as of August 2026. 57 certified beds, 54 residents a day on average. 21 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $16,801.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★☆☆ 3 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / — of 5 |
Staffing
| Total nurse staffing | 3.10152 hours per resident per day |
|---|---|
| Registered nurses | 0.61673 hours per resident per day |
| Weekend total | 2.90502 hours per resident per day |
| Nursing staff turnover | 46.3% (registered nurses 63.6%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-07-07 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-27 |
| 2025-03-25 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-01-17 |
| 2024-12-19 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-01-17 |
| 2024-12-19 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-17 |
| 2024-12-19 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-17 |
| 2024-12-19 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-01-17 |
| 2024-05-01 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2024-02-07 |
| 2024-01-25 complaint survey |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · tag F0925 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-02-21 |
| 2024-01-25 complaint survey |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-19 |
| 2023-07-17 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-08-09 |
| 2023-07-17 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 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. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-09 |
| 2023-07-17 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 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. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2019-11-22 |
| 2019-10-31 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · tag F0744 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2019-12-02 |
| 2019-10-31 | Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · tag F0923 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 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. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2019-11-15 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-05-01 | Fine | $16,801 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Chief Joseph Trail, LLC Organization | 5% or greater direct ownership interest | 100% | 2026-03-02 |
| Tippet, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| White Canyon, LLC Organization | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Madison Creek Partners LLC Organization | adp of the snf | — | 2025-11-13 |
| Madison Creek Partners LLC Organization | operational/managerial control | — | 2013-06-01 |
| Clegg, Michael Individual | 5% or greater indirect ownership interest | — | 2026-03-02 |
| Christensen, Covey Individual | adp of the snf | — | 2013-06-01 |
| Clegg, Michael Individual | adp of the snf | — | 2023-06-26 |
| Hopkins, Amber Individual | adp of the snf | — | 2021-12-01 |
| Howe, Robert Individual | adp of the snf | — | 2018-06-01 |
| Ikerd, John Individual | adp of the snf | — | 2022-04-25 |
| James, Kendra Individual | adp of the snf | — | 2023-06-01 |
| Clegg, Michael Individual | managing control - governing body | — | 2023-06-26 |
| Ikerd, John Individual | managing control - governing body | — | 2026-03-02 |
| Christensen, Covey Individual | operational/managerial control | — | 2013-06-01 |
| Clegg, Michael Individual | operational/managerial control | — | 2023-06-26 |
| Hopkins, Amber Individual | operational/managerial control | — | 2021-12-01 |
| Howe, Robert Individual | operational/managerial control | — | 2018-06-01 |
| Ikerd, John Individual | operational/managerial control | — | 2022-04-25 |
| James, Kendra Individual | operational/managerial control | — | 2023-06-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Lakewood Villa.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Jefferson County.