LAKEWOOD VILLA

CCN 065408 · LAKEWOOD VILLA OPERATIONS, LLC · For profit - Limited Liability company · MADISON CREEK PARTNERS chain · 57 certified beds · Jefferson · CO


LAKEWOOD VILLA is a 57-bed nursing home in LAKEWOOD, Colorado. CMS has certified it for Medicare and Medicaid since 2013-06-01. It averages 53.9 residents a day.

What harm was found in the violations cited at LAKEWOOD VILLA?

CMS lists 21 health-inspection deficiencies for LAKEWOOD VILLA since 2019-10-31, 10 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is J; the most recent health inspection was 2025-07-07.

Survey dateTagDeficiencySeverity
2025-07-07F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2025-03-25F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2024-12-19F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2024-12-19F0880Provide and implement an infection prevention and control program.E
2024-12-19F0759, F0760, F0600Ensure medication error rates are not 5 percent or greater. / Ensure that residents are free from significant medication errors. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2024-05-01F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J
2024-01-25F0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.F
2024-01-25F0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.E
2023-07-17F0689, F0692Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health.G
2023-07-17F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2023-07-17F0761Ensure 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.E
2023-07-17F0553, F0600, F0758Allow resident to participate in the development and implementation of his or her person-centered plan of care. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / 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.D
2019-10-31F0600, F0744Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.G
2019-10-31F0923Have enough outside ventilation via a window or mechanical ventilation, or both.E
2019-10-31F0625Notify 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.D

Why was LAKEWOOD VILLA fined?

DateTypeAmount
2024-05-01Fine$16,801

How is LAKEWOOD VILLA staffed relative to the CO average?

MeasureThis facilityCO average
Total nurse staffing hours per resident per day3.101523.72368
Total nursing staff turnover (%)46.347.1
Average number of residents per day53.974.8

Who owns LAKEWOOD VILLA, and what chain is it in?

LAKEWOOD VILLA is registered with CMS as For profit - Limited Liability company, operates under the legal business name LAKEWOOD VILLA OPERATIONS, LLC and belongs to the MADISON CREEK PARTNERS chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTCHIEF JOSEPH TRAIL, LLCsince 03/02/2026
5% OR GREATER INDIRECT OWNERSHIP INTERESTTIPPET, LLC, WHITE CANYON, LLC, CLEGG, MICHAELsince 03/02/2026
MANAGING CONTROL - GOVERNING BODYCLEGG, MICHAEL, IKERD, JOHNsince 03/02/2026
OPERATIONAL/MANAGERIAL CONTROLMADISON CREEK PARTNERS LLC, CHRISTENSEN, COVEY, CLEGG, MICHAEL, HOPKINS, AMBER, HOWE, ROBERT, IKERD, JOHN, JAMES, KENDRAsince 04/25/2022
ADP OF THE SNFMADISON CREEK PARTNERS LLC, CHRISTENSEN, COVEY, CLEGG, MICHAEL, HOPKINS, AMBER, HOWE, ROBERT, IKERD, JOHN, JAMES, KENDRAsince 04/25/2022

Were you or a family member harmed at LAKEWOOD VILLA?