Cycle 1
Health 2024-12-19 · Fire 2024-12-19
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lakewood, CO
Lakewood Villa
3-star overall rating with 2-star inspections with abuse icon flag with $40,006 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1625 Simms St, Lakewood, CO
(303) 238-8161
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Madison Creek Partners
Operator or chain grouping
Approved since
2013-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.44
Licensed practical nurse staffing
Aide hours / resident day
1.96
Nurse aide staffing
Weekend hours
2.82
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 63.2% |
93.5%
30.3 pts worse
|
93.4%
30.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 75.0% |
94.7%
19.7 pts worse
|
95.5%
20.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.4%
0.8 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
7.4%
6.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.0%
0.4 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.2% |
11.2%
5 pts better
|
19.6%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 64.3% |
20.6%
43.7 pts worse
|
16.7%
47.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.4% |
15.2%
0.8 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
14.6%
6.5 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
22.4%
6.7 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.3% |
3.7%
2.4 pts better
|
5.1%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 10.9% |
76.4%
65.5 pts worse
|
81.7%
70.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-17 · Fire 2023-07-17
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-10-31 · Fire 2019-10-31
7 health deficiencies
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-01-31
F · Potential for more than minimal harm
2024-12-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-12
F · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-30
F · Potential for more than minimal harm
2024-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-12-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-23
E · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-07
E · Potential for more than minimal harm
2024-12-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-01-23
F · Potential for more than minimal harm
2023-07-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-03
F · Potential for more than minimal harm
2023-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-07-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-07-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-07-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-10-03
F · Potential for more than minimal harm
2019-10-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-03
F · Potential for more than minimal harm
2019-10-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-27
F · Potential for more than minimal harm
2019-10-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-11-27
D · Potential for more than minimal harm
2019-10-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-12-02
D · Potential for more than minimal harm
2019-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-27
D · Potential for more than minimal harm
2025-03-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-25
F · Potential for more than minimal harm
2024-12-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-17
J · Immediate jeopardy
2024-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-07
F · Potential for more than minimal harm
2024-01-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-02-21
E · Potential for more than minimal harm
2024-01-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-19
G · Actual harm
2023-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-09
G · Actual harm
2023-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-09
F · Potential for more than minimal harm
2023-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-07-17
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-17
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-03-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-27
G · Actual harm
2019-10-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-11-22
G · Actual harm
2019-10-31
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-12-02
E · Potential for more than minimal harm
2019-10-31
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2019-11-10
D · Potential for more than minimal harm
2019-10-31
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-11-15
Penalties and ownership
What sits behind the stars
$16,801
2024-05-01
Fine
Fine · fine $16,801
Fine
$0
2023-08-08
Payment Denial
Payment Denial · denial start 2023-11-08 · 6 days
6 day denial
$23,205
2023-07-17
Fine
Fine · fine $23,205
Fine
Ownership
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