Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakewood Villa during CMS and state inspections, most recent first.
Two residents with cognitive and behavioral issues were involved in a physical altercation in the dining room, resulting in minor injury and property damage. The care plan intervention to assist one resident to an appropriate table to prevent such incidents was not included in the Kardex, the main reference for CNAs, leading to staff being unaware of necessary precautions and contributing to the failure to prevent the abuse.
A resident with dementia and aggressive behaviors was involved in multiple physical altercations with other residents, resulting in injuries and highlighting a failure in the facility's abuse prevention measures. Despite interventions and care plan updates, the resident's aggressive behavior persisted, indicating inadequate protection for other residents.
The facility failed to ensure sanitary conditions in the main kitchen by not monitoring the dishwashing machine's temperature and chemical concentration. Staff lacked training and knowledge, leading to inconsistent documentation and inadequate sanitization of tableware, drinkware, and cookware.
The facility failed to maintain an effective infection control program, with housekeeping staff not using proper cleaning techniques or disinfectants on high-touch surfaces, and failing to implement enhanced barrier precautions for a resident with a stage IV pressure injury. Additionally, the facility did not maintain proper temperature logs for washing machines, indicating a lack of adherence to infection control protocols.
A resident with dementia and behavioral disturbances was not protected from physical abuse by an agency RN, who was captured on video knocking a cup from the resident's hand and pushing him. The incident was discovered during a routine review of security footage, despite initial concerns raised by an agency CNA about resident treatment. The facility's policy required immediate reporting of suspected abuse, but the initial report did not lead to immediate action.
A LTC facility reported a medication error rate of 6.45%, exceeding the acceptable threshold. An RN failed to prime an insulin pen before administering it to a diabetic resident, and also applied Voltaren gel without a specified dose to another resident. The RN was unaware of the need to prime the pen and use the dosing card, indicating a lack of adherence to medication administration protocols.
A resident with diabetes received an incorrect insulin dose due to a nurse's failure to prime the insulin pen before administration. The RN was unaware of the need to prime the pen, contrary to facility policy and professional guidelines. Interviews revealed a lack of understanding among staff about proper insulin pen usage.
The facility failed to provide adequate supervision and necessary assistive devices to prevent the elopement of two residents with severe mental health disorders. One resident suffered frostbite after being found outside, and another was found by police at a busy intersection. Staff were unaware of the residents' absences due to ineffective alarm systems and inadequate training.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Incomplete Care Planning
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, as required by its abuse prevention policies. An incident occurred in the dining room where one resident reported being kicked, grabbed, and hit on the chest by another resident while walking to dinner. In response, the first resident struck the second resident in self-defense. Staff did not witness the event, and it was not captured on facility cameras. The incident resulted in a minor injury—a bruise above the left eye of one resident—and damage to his eyeglasses. Both residents involved had documented cognitive impairments and behavioral issues. One resident had a diagnosis of dementia, was cognitively intact per recent assessment, and had a care plan addressing agitation and physical outbursts. The other resident had moderate cognitive impairment, dementia, and a history of making uninvited sexual advances and explicit comments, with care plans for behavioral monitoring and antipsychotic medication. Despite these documented risks, the care plan intervention to assist the second resident to an appropriate table in the dining room to prevent collisions with other residents was not included in the resident's Kardex, which is the primary tool used by CNAs for care guidance. Staff interviews revealed that CNAs relied on the Kardex for resident-specific interventions and were unaware of the missing intervention for the second resident. The assistant director of nursing confirmed that the intervention to assist the resident to an appropriate table had not been added to the Kardex at the time of the incident. This omission contributed to the failure to prevent the altercation between the two residents, as staff were not adequately informed or equipped to implement the necessary preventive measures.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect several residents from physical abuse, as evidenced by multiple incidents involving Resident #3. Resident #3, who has a history of dementia with agitation, was involved in physical altercations with other residents. On one occasion, Resident #3 physically assaulted Resident #2 by hitting her in the eye with a closed fist, resulting in an abrasion and bruise. This incident was witnessed by a housekeeper who intervened to separate the residents. Despite the intervention, Resident #3's aggressive behavior continued, indicating a failure in the facility's measures to prevent abuse. In another incident, Resident #3 was involved in a physical altercation with Resident #6. The altercation began with verbal aggression and escalated when Resident #3 pushed Resident #6, who then retaliated by pushing Resident #3 to the floor. This resulted in Resident #3 sustaining a bruise on his elbow. The facility's response included separating the residents and updating their care plans, but the repeated nature of these incidents suggests inadequate preventive measures were in place. Additionally, Resident #3 was involved in an incident with Resident #9, where he slapped Resident #9 on the head after a confrontation involving a chair. This incident occurred during the survey and was immediately reported to the LPN and NHA. Despite the facility's policy on abuse prevention and the interventions in place, the repeated incidents involving Resident #3 highlight a significant deficiency in protecting residents from abuse and ensuring their safety.
Failure to Monitor Dishwashing Machine Sanitization
Penalty
Summary
The facility failed to ensure that food items were stored, prepared, distributed, and served under sanitary conditions in the main kitchen. Specifically, the facility did not have a system in place to monitor the internal water temperature and concentration of hypochlorite in the dish machine to ensure effective sanitization of tableware, drinkware, and cookware. The Colorado Retail Food Establishment Rules and Regulations require a test kit or device to measure the concentration of sanitizing solutions, and the facility's policy required regular checks and documentation of sanitizer concentrations and temperatures. Observations and interviews revealed that the dietary manager (DM) and dietary aides (DA) were not consistently monitoring or documenting the temperature and chemical concentration of the dishwashing machine. The DM admitted that test strips were unavailable for several days, and staff relied solely on the machine's temperature gauge, which was often below the required 120°F. The dishwasher temperature log showed multiple instances of missing or inadequate temperature recordings, and there was no documentation of the parts per million (ppm) of the chemical sanitizer being monitored. Interviews with staff, including the infection preventionist (IP) and dietary aides, highlighted a lack of knowledge and training regarding the correct temperature and chemical concentration requirements for effective sanitization. The DM acknowledged that the logs were incomplete and that staff were not adequately trained to use the test strips or document the ppm levels. The DM also admitted to having the necessary test strips but was unaware they could be used for the dishwashing machine, indicating a significant gap in staff training and procedural adherence.
Infection Control Deficiencies in Housekeeping and Laundry
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies in housekeeping practices. Observations revealed that housekeeping staff did not follow proper cleaning techniques, such as using disinfectants on high-touch surfaces like door knobs, light switches, call lights, and bed controllers. Additionally, the staff used incorrect cleaning products, such as dish soap instead of disinfectants, and failed to use disinfectants in mop buckets, which only contained plain water. The housekeeping staff also improperly used cleaning tools, such as using a toilet brush on surfaces outside the toilet bowl, and did not discard contaminated personal items found during cleaning. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a stage IV pressure injury. During wound care, the wound care physician and a registered nurse did not use the necessary personal protective equipment (PPE) such as gowns and gloves, as required by the facility's EBP policy. The staff was unaware of the need for EBP for this resident, indicating a lack of awareness and training regarding infection control measures for residents with chronic wounds. In the laundry department, the facility did not maintain proper temperature logs for washing machines, which are necessary to ensure effective disinfection of laundry. The housekeeping and laundry manager was unaware of the requirement to check washing machine temperatures, and the infection preventionist did not know the frequency or the required temperature for washing machines. This lack of monitoring and adherence to infection control protocols in the laundry process further contributed to the facility's failure to maintain a safe and sanitary environment.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved an agency registered nurse (RN) who was captured on video surveillance swinging her arm and knocking a cup of water out of the resident's hand, followed by pushing the resident, causing him to stumble backward. This incident was discovered during a routine review of security footage by the nursing home administrator (NHA) and the director of nursing (DON). The resident involved was over 65 years old and had diagnoses including dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD), and depression. The resident was severely cognitively impaired and required assistance with daily activities. On the night of the incident, the resident exhibited increased behaviors such as exit-seeking and agitation, which were documented in behavior notes. Despite these behaviors, the resident was not physically aggressive towards others according to the minimum data set (MDS) assessment. The facility's policy required immediate reporting of any suspected abuse to the administrator and other officials as per state law. However, the initial report from an agency certified nurse aide (CNA) about concerns regarding resident treatment did not lead to immediate action, as the CNA did not provide specific details and hung up on the DON. The agency RN involved in the incident continued to work her scheduled shifts until the video footage was reviewed, revealing the abuse. The facility's failure to act promptly on the initial report and the subsequent discovery of the abuse through video surveillance highlight the deficiency in protecting the resident from abuse.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45% due to two errors out of 31 opportunities. One error involved a registered nurse (RN) administering Humalin R U-500 Kwik pen insulin to a resident with diabetes without priming the pen, which is necessary to ensure the correct dose is delivered. The RN was unaware of the need to prime the pen, believing it would waste insulin, and was not familiar with the facility's protocol regarding insulin pens. This oversight was contrary to professional standards and the facility's policy, which emphasize the importance of following the seven rights of medication administration. Another error occurred when the same RN administered Voltaren arthritis pain gel to a resident with osteoarthritis without a specified dose in the medication order. The RN applied the gel without using the dosing card provided with the medication, as he was unaware of its necessity. The Director of Nursing (DON) confirmed that orders should include all necessary details, including the dose, and that the dosing card should be used to ensure the correct amount is applied. These errors highlight a lack of adherence to established medication administration protocols and insufficient staff training on medication procedures.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin using insulin pens. A registered nurse (RN) did not prime the insulin pen before administering the medication to a resident, which is a necessary step to ensure the correct dose is delivered. The RN was unaware of the need to prime the pen, believing it would waste insulin, and was also not informed about the facility's protocol regarding insulin pen usage. This oversight was observed during a medication administration for a resident with type one diabetes, obesity, and paranoid schizophrenia, who required insulin injections as part of their treatment. The facility's policy on administering medications emphasizes the importance of verifying the right resident, medication, dose, time, and method before administration. However, the RN did not follow the professional reference guidelines for insulin pen usage, which state that priming is essential to remove air from the needle and cartridge. Interviews with the RN and a licensed practical nurse (LPN) revealed a lack of awareness and understanding of the correct procedure for insulin pen usage. The director of nursing (DON) confirmed that priming is crucial to ensure the correct dose is administered and acknowledged the failure to adhere to this practice.
Failure to Prevent Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision and necessary assistive devices to prevent the elopement of two residents diagnosed with severe mental health disorders. Resident #1, who had schizoaffective disorder and required continuous supervision, eloped from the facility by exiting through an alarmed dining room door and an unlocked outside gate. The staff were unaware of the resident's absence until 33 minutes later when an agency certified nurse aide (ACNA) found the resident outside, stuck in a construction site fence, and suffering from frostbite. The facility's investigation revealed that the staff did not respond to the door alarm, which stopped sounding after 90 seconds and required a manual reset with a key. Despite initial corrective actions, the facility failed to prevent a second elopement incident involving Resident #2, who had paranoid schizophrenia and dementia. This resident also exited through the same alarmed dining room door and unlocked gate. The local police found the resident at a busy intersection and transported him to a hospital for evaluation. The facility's investigation determined that the door alarm did not sound, and the gate was again unlocked. Staff were not aware of the resident's absence until notified by the police. Both incidents highlight the facility's failure to ensure staff were properly trained to respond to door alarms and secure the premises. The facility's initial corrective measures, including staff education and monitoring through QAPI meetings, proved ineffective in preventing further elopements. The deficiencies in supervision and security measures created situations with serious harm and the likelihood of serious harm to the residents' health and safety.
Removal Plan
- Resident #2's care plan was updated to include providing activities to attempt giving the resident meaningful activities.
- Facility to add a chirping alarm to dining room doors.
- Nursing to conduct frequent checks for resident's whereabouts.
- The facility ordered new door alarms. The new alarm system had no automatic shut off and the alarm continued to sound until it was turned off by the facility staff and rearmed with a key.
- The facility ordered items to rebuild the entire egress area (where the outside gate was opened). The ordered items included black aluminum fence panels, fast setting concrete mix, a new gate door, door hardware for installation, and a battery operated powered door mounted weatherized exit alarm.
- Facility staff were educated on how to turn the current alarms off until the new door alarms were installed.
- The staffing agency was notified via text of the elopement binder with directions of how to turn the current alarms off which was to be read by all agency staff before each person worked in the facility.
- Visual aide note cards were added to the doors about how the keys were to turn to reset the alarms on the doors.
- The new door alarms were installed and staff education of how to work the alarms began.
- Weekly documentation of safety checks on the door alarms was started by the plant operations director (POD).
- The outside gate improvement project was completed. Weekly checks of the outside gate area were started.
- The new door alarm system was installed which removed the immediacy of the deficient practice. The outdoor gate improvement project was an additional security measure put in place by the facility, however, it was not the main security issue, therefore the correction date for the deficient practice was the installation of the new door alarm system.
- The facility would monitor the elopement situation and the weekly safety check documentation in the monthly QAPI meetings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahc Of Lakewood, Llc | 0.5 mi | ★★★★★ | 6 | 0 |
| Allison Care Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Western Hills Health Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Harmony Pointe Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Mountain Vista Health Center | 2.9 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.