Cycle 1
Health 2023-12-14 · Fire 2023-12-14
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Lakewood, CO
Villa Manor Care Center
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
7950 W Mississippi Ave, Lakewood, CO
(303) 986-4511
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Centers Of America
Operator or chain grouping
Approved since
1971-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
194 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,020
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.03
Composite VBP score used to determine payment impact.
Payment multiplier
1.0161
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.92
Baseline 16.57% · Performance 17.76% · Measure score 7.92 · Achievement 7.92 · Improvement 0
Healthcare-associated infections
8.60
Baseline 6.48% · Performance 5.26% · Measure score 8.60 · Achievement 8.60 · Improvement 7.69
Total nurse turnover
5.73
Baseline 57.94% · Performance 40.26% · Measure score 5.73 · Achievement 5.73 · Improvement 4.84
Adjusted total nurse staffing
2.16
Baseline 3.66 hours · Performance 3.69 hours · Measure score 2.16 · Achievement 2.16 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 7.91% · Lower 95% interval 7.08% |
| Discharge to community | 56.25% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 50.34% · Lower 95% interval 49.44% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.41% |
95.27%
3.1 pts better
|
Numerator 62 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 69.05% |
53.69%
15.4 pts better
|
Numerator 29 · Denominator 42 |
| Discharge mobility score | 54.76% |
50.94%
3.8 pts better
|
Numerator 23 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 3.17% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 63 · Adjusted rate 2.75% |
| Healthcare-associated infections requiring hospitalization | 5.26% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 1.35% · Lower 95% interval 2.63% |
| Staff COVID-19 vaccination coverage | 8.75% |
8.2%
0.6 pts better
|
Numerator 14 · Denominator 160 |
| Staff flu vaccination coverage | 73.21% |
42%
31.2 pts better
|
Numerator 164 · Denominator 224 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 30 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 32.43% |
25.2%
7.2 pts better
|
Numerator 12 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
93.5%
3.7 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 96.2% · Q3 96.4% · Q4 98.2% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
94.7%
1.8 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.4%
2.9 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.8% |
7.4%
1.6 pts better
|
11.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 7.4% · Q4 11.3% · 4Q avg 5.8% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.0%
3.4 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 2.2% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.9% |
11.2%
4.3 pts better
|
19.6%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.7% · Q3 8.2% · Q4 4.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
20.6%
7.1 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 12.8% · Q3 14.6% · Q4 10.3% · 4Q avg 13.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.4% |
15.2%
9.8 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.8% |
14.6%
4.8 pts better
|
14.9%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.9% · Q3 10.4% · Q4 13.0% · 4Q avg 9.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.5%
2.3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 3.7% · Q4 3.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
22.4%
10.8 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 33.7% · Q3 31.5% · Q4 43.1% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
3.7%
3.3 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
76.4%
8.6 pts better
|
81.7%
3.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.3% · Q2 82.2% · Q3 83.2% · Q4 88.6% · 4Q avg 85.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.8%
2 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.9% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
75.6%
7.7 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
20.3%
2.1 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 22.6% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-02 · Fire 2022-09-02
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-11
F · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-12-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-31
F · Potential for more than minimal harm
2023-12-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-02
F · Potential for more than minimal harm
2023-12-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-15
F · Potential for more than minimal harm
2023-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-02
E · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-12-14
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 2024-02-02
D · Potential for more than minimal harm
2023-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-02
F · Potential for more than minimal harm
2022-09-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-09-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
F · Potential for more than minimal harm
2022-09-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-02
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 2022-11-03
D · Potential for more than minimal harm
2022-09-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-25
E · Potential for more than minimal harm
2025-03-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-25
E · Potential for more than minimal harm
2024-03-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-05-03
E · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-12-14
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 2024-01-19
E · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-25
D · Potential for more than minimal harm
2023-12-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-25
D · Potential for more than minimal harm
2023-12-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-19
D · Potential for more than minimal harm
2023-12-14
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-10-11
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-10
D · Potential for more than minimal harm
2022-09-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-10-18
D · Potential for more than minimal harm
2022-09-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-18
F · Potential for more than minimal harm
2019-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-20
E · Potential for more than minimal harm
2019-09-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-10-20
E · Potential for more than minimal harm
2019-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-10-20
E · Potential for more than minimal harm
2019-09-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-10-20
E · Potential for more than minimal harm
2019-09-12
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 2019-10-20
D · Potential for more than minimal harm
2019-09-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-10-20
Penalties and ownership
What sits behind the stars
Ownership
Preston, Forrest
5% Or Greater Direct Ownership Interest · Individual
Cross, Cindy
Corporate Officer · Individual
Developers Investment Company Inc
General Partnership Interest · Organization
Life Care Centers Of America, Inc.
Operational/Managerial Control · Organization
Preston, Forrest
Limited Partnership Interest · Individual
Strong, Jessica
W-2 Managing Employee · Individual
Thurmond, Joan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mapleton Post Acute
Lakewood, CO
3-star overall rating with 2-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Oakwood Care And Rehabilitation
Lakewood, CO
1-star overall rating with 1-star inspections with $235,923 in total fines with 13 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Lakewood Post Acute And Rehabilitation
Lakewood, CO
2-star overall rating with 2-star inspections with $49,137 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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