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Lakewood Villa

For profit - Partnership  ·  1625 Simms St, Lakewood, CO 80215  ·  See home’s Medicare page

Affiliated With Madison Creek Partners
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
2.89
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.7
73.5%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 55.2%
57
Certified beds
Qualifying beds in the certified provider or supplier facility.
45
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
No direct owner information
Indirect owners
Madison Creek Partners Llc
Covey Christensen
Managerial control
Covey Christensen since Jun, 2015
Managing employee(s)
No information available

Inspection Reports

15

total deficiencies

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
May 1, 2024
Complaint report
1 deficiency
$25,847 Fine
J

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Immediate jeopardy to resident health or safety
Scope
Few people affected
Seriousness
J

Jan 25, 2024
Complaint report
2 deficiencies
E

to F
F

Environmental Deficiency — F0925
Failure to: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Environmental Deficiency — F0921
Failure to: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Jul 17, 2023
Standard report
7 deficiencies
$23,205 Fine
D

to G
G

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Nutrition and Dietary Deficiency — F0812
Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
F

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0553
Failure to: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0758
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Mar 22, 2023
Complaint report
1 deficiency
D

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Oct 31, 2019
Standard report
4 deficiencies
D

to G
G

Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Quality of Life and Care Deficiency — F0744
Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
G

Environmental Deficiency — F0923
Failure to: Have enough outside ventilation via a window or mechanical ventilation, or both.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0625
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$149K

total fines

1

payment suspension

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
May 1, 2024
Aug 8, 2023
1 Payment Suspension
No corresponding inspection report.
Jul 17, 2023
Feb 21, 2023
No corresponding inspection report.
Feb 13, 2023
No corresponding inspection report.
Feb 6, 2023
No corresponding inspection report.
Jan 30, 2023
No corresponding inspection report.
Jan 23, 2023
No corresponding inspection report.
Jan 17, 2023
No corresponding inspection report.
Jan 9, 2023
No corresponding inspection report.
Jan 3, 2023
No corresponding inspection report.
Dec 27, 2022
No corresponding inspection report.
Dec 19, 2022
No corresponding inspection report.
Dec 12, 2022
No corresponding inspection report.
Dec 5, 2022
No corresponding inspection report.
Nov 28, 2022
No corresponding inspection report.
Nov 21, 2022
No corresponding inspection report.
Nov 15, 2022
No corresponding inspection report.
Nov 7, 2022
No corresponding inspection report.
Oct 17, 2022
No corresponding inspection report.
Aug 22, 2022
No corresponding inspection report.
Aug 16, 2022
No corresponding inspection report.
Aug 8, 2022
No corresponding inspection report.
Jul 18, 2022
No corresponding inspection report.