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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 76th out of 177 homes in Colorado. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 2h 47m per day |
Higher than the Colorado average: 76.5%Lakewood Villa is administrated by Kendra James.
In Colorado, the Department of Public Health and Environment, Health Facilities Division is the regulatory body that performs unannounced surveys and publishes facility inspection findings.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Colorado state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | CO Average | vs. CO Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 37 | 30 | This facility has 23% more total deficiencies than a typical Colorado nursing home (37 vs. CO avg 30).↑ 23% worse |
|
Deficiencies per year
Average deficiencies per year since 2019.
| 5.3 | 4.3 | This facility has 23% more deficiencies per year than a typical Colorado nursing home (5.3 vs. CO avg 4.3).↑ 23% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
This facility’s inspection record is mixed, with repeated failures to protect residents from physical abuse by other residents and staff, alongside ongoing issues in infection control and supervision. The most recent inspection on July 7, 2025, substantiated abuse between residents and cited two deficiencies related to abuse prevention and care planning. Earlier inspections documented multiple substantiated abuse complaints, housekeeping and infection control lapses in December 2024, and inadequate supervision leading to elopements and falls in 2024 and 2023.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsColorado average 4.8
Last Health inspection on Jul 2025
Colorado average 24.8
Colorado average 5.2
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
13 of 22 citations resulted from standard inspections; 6 of 22 resulted from complaint investigations; and 3 of 22 came from combined inspections (standard and complaint).
150% worse than Colorado averageColorado average: 0.4
90% worse than Colorado averageColorado average: 2.1
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
45% better than Colorado average
10% better than Colorado average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.4 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.5 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.4 hoursThis role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
2,157 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 22 | 41 | 63 | 9,919 | 92 | 100% | 9.4 |
| Registered Nurse | 8 | 15 | 23 | 2,359 | 92 | 100% | 9.4 |
| Licensed Practical Nurse | 5 | 14 | 19 | 2,290 | 92 | 100% | 9.5 |
| Speech Language Pathologist | 2 | 0 | 2 | 515 | 64 | 70% | 7.7 |
| Administrator | 1 | 0 | 1 | 512 | 64 | 70% | 8 |
| Nurse Practitioner | 1 | 0 | 1 | 512 | 64 | 70% | 8 |
| Clinical Nurse Specialist | 1 | 0 | 1 | 512 | 64 | 70% | 8 |
| Other Dietary Services Staff | 2 | 0 | 2 | 477 | 68 | 74% | 7 |
| Nurse Aide in Training | 1 | 0 | 1 | 228 | 19 | 21% | 12 |
| Respiratory Therapy Technician | 2 | 0 | 2 | 183 | 20 | 22% | 7.9 |
| Dental Services Staff | 1 | 0 | 1 | 139 | 17 | 18% | 8.2 |
| Physical Therapy Assistant | 3 | 0 | 3 | 20 | 7 | 8% | 2.8 |
| Physical Therapy Aide | 1 | 0 | 1 | 6 | 3 | 3% | 2.1 |
Includes penalties issued in 2023-2024
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
94% higher than Colorado averageColorado average: $40K
350% more fines than Colorado averageColorado average: 2.2
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
1
276% more payment denials than Colorado averageColorado average: 0.3
Penalties are imposed by CMS for violations of federal nursing home regulations.
3 penalties in the past 3 years
Multiple penalties were reported in the last 3 years.
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
May 1, 2024
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
Aug 8, 2023
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Jul 17, 2023Last updated: Jan 2026
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
11.5
28% worse than Colorado averageColorado average: 9.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
24.8
32% worse than Colorado averageColorado average: 18.8
Percent of long-stay residents whose need for help with daily activities has increased
23.9%
49% worse than Colorado averageColorado average: 16.0%
Percent of long-stay residents whose ability to move independently worsened
19.0%
12% worse than Colorado averageColorado average: 17.0%
Percent of low risk long-stay residents who lose control of their bowels or bladder
31.5%
36% worse than Colorado averageColorado average: 23.2%
Percent of long-stay residents experiencing one or more falls with major injury
4.3%
29% worse than Colorado averageColorado average: 3.3%
Percent of long-stay high risk residents with pressure ulcers
3.1%
21% better than Colorado averageColorado average: 3.9%
Percent of long-stay residents with a urinary tract infection
1.1%
23% better than Colorado averageColorado average: 1.4%
Percent of long-stay residents who lose too much weight
7.5%
43% worse than Colorado averageColorado average: 5.2%
Percent of long-stay residents who have depressive symptoms
2.2%
70% better than Colorado averageColorado average: 7.2%
Percent of long-stay residents who received an antipsychotic medication
61.1%
225% worse than Colorado averageColorado average: 18.8%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
78.5%
16% worse than Colorado averageColorado average: 93.3%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
75.0%
21% worse than Colorado averageColorado average: 94.7%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
25.5%
67% worse than Colorado averageColorado average: 76.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
44Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for Lakewood Villa based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #151 / 182Payroll — State benchmarkedThis home is ranked 151st out of 182 homes in Colorado. Shows total annual staff payroll benchmarked to the Colorado average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
0.0 miles from city center
Estimated distance in miles from Lakewood's city center to Lakewood Villa's address, calculated via Google Maps.
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Lakewood Villa is located in LAKEWOOD, Colorado.
Here are the financial assistance programs available to residents in Colorado.
The information below is reported by the Colorado Department of Public Health and Environment, Health Facilities Division.
| Ahc of Lakewood LLC |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Lakewood | 36 | 75.2% | -2% | 5.12 | +12% | +33% | $72.6k | 7 | 7.0 | - | 30 | - | 68 | Mauricio Waintrub | $9.2M | $4.1M | 44.6% | 65435 | ||||
| Villa Manor Care Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Lakewood | 110 | 71.5% | -7% | 3.91 | -6% | +1% | $0 | 27 | 4.5 | - | 77 | - | 70 | Developers Investment Company Inc | $13.7M | $8.0M | 58.5% | 65092 | ||||
| Lakewood Villa |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Lakewood (South Alameda) | 57 | 86.2% | +13% | 3.82 | +36% | -1% | $104.1k | 22 | 2.8 | 5 | 52 | A | 85 | - | $6.6M | $3.8M | 57.9% | 65408 | ||||
| Bethany Nursing and Rehab |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Lakewood | 170 | 65.3% | -15% | 3.24 | -5% | -16% | $235.9k | 65 | 8.1 | 11 | 108 | - | 57 | - | $14.7M | $9.4M | 64.1% | 65248 | ||||
| Woodlake Legacy Senior Living | - |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Lakewood (Foothills) | 131 | 51.4% | -33% | - | - | - | - | - | - | - | - | - | - | - | - | 71 | #N/A | $7.6M | $3.1M | 41% | 65374 |
Lakewood Villa is in the South Alameda neighborhood of LAKEWOOD.
The legal owner and operator of Lakewood Villa is Lakewood Villa Operations, Llc.
Lakewood Villa has a walk score of 85. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
Lakewood Villa's occupancy is 88%.
Kendra James is the administrator of Lakewood Villa.
Lakewood Villa has 57 beds.
Yes — there are 19 photos of Lakewood Villa in the photo gallery on this page.
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