LAKEWOOD, CO - Federal inspectors documented serious mental health care failures at Lakewood Post Acute and Rehabilitation during a March 2025 inspection, finding the facility failed to provide appropriate treatment and monitoring for a resident with a documented history of suicide attempts.
Resident Denied Requested Mental Health Services
A 66-year-old resident recovering from a car accident specifically requested to see a therapist but received no mental health services despite having a documented history of suicide attempts and experiencing multiple traumatic losses. The resident had lost her mother months earlier, was approaching the anniversary of her nephew's murder, and faced uncertainty about her future living situation.
During the inspection interview, the resident became tearful and explained she had asked the social services director for therapy because she felt she needed to talk to someone. She reported hearing nothing about a therapist appointment despite her request.
Federal records show the resident's trauma history included family issues, loss of mother in December 2024, murder of nephew in March 2022, life-threatening illness, suicide attempt by overdose, and recent breakup with her longtime partner. Her care plan acknowledged she was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, and poor impulse control.
Lack of Suicide Risk Monitoring
Despite the resident's documented suicide attempt history and current traumatic stressors, the facility failed to implement appropriate monitoring protocols. Medical orders included psychological evaluation and treatment, antidepressant medications, and behavior monitoring for tearful or sad expressions, but did not include specific monitoring for signs and symptoms of suicidal ideation.
The social services director acknowledged completing a trauma assessment and knowing about the resident's past suicide attempt but did not establish behavior monitoring for suicidal ideations. She told inspectors she relied on the resident's statement that she would not attempt suicide again, despite acknowledging the resident had increased stressors since her prior suicide attempt.
Mental health conditions require comprehensive monitoring and intervention strategies. When individuals with suicide history experience multiple stressors simultaneously, the risk of crisis increases significantly. Standard protocols typically include regular mental health assessments, suicide risk screening, and immediate access to crisis intervention services.
Staff Unaware of Critical Mental Health Information
Nursing staff demonstrated limited awareness of the resident's mental health risks and trauma history. A licensed practical nurse knew the resident exhibited signs of depression and had lost her mother recently but was unaware of other traumatic events or suicide attempt history. A certified nursing aide knew about the nephew's murder anniversary but was similarly unaware of other significant trauma or suicide attempts.
This communication gap represents a critical safety concern. When staff members are unaware of residents' mental health risks, they cannot properly monitor for warning signs or respond appropriately to behavioral changes that might indicate increased suicide risk.
Dietary Violations Put Kidney Patient at Risk
Inspectors also documented dietary management failures affecting a resident with acute kidney failure. The 80-year-old resident was prescribed a renal diet but regularly received high-potassium foods including potatoes, tomatoes, and bananas - foods that can be dangerous for people with kidney disease.
High potassium levels in the blood, called hyperkalemia, can cause irregular heartbeat and potentially heart attack in severe cases. The resident told inspectors she was aware she should avoid high-potassium foods but frequently received inappropriate items on her meal trays, which she left uneaten.
The facility's nutrition service manager acknowledged errors in their electronic ticket system and was working to implement better verification processes to ensure meal accuracy.
Infection Control Failures Throughout Facility
Multiple infection control violations were documented during the inspection, including improper use of personal protective equipment (PPE) and inadequate cleaning procedures.
Staff members repeatedly failed to follow proper isolation protocols. A housekeeper entered multiple resident rooms wearing the same surgical mask after visiting a resident on droplet precautions. An oxygen supplier entered an isolation room without any PPE and came within three feet of the resident. The nutrition service manager improperly donned PPE by entering an isolation room to retrieve equipment before putting on protective gear.
Cleaning Procedures Below Standards
Housekeeping staff demonstrated unsafe cleaning practices that could spread infections rather than prevent them. Inspectors observed a housekeeper immediately wiping disinfectant spray instead of allowing the required one-minute contact time for effectiveness. The same staff member used contaminated rags to clean grab bars without applying any disinfectant, and cleaned toilets in an unsanitary manner by dipping rags into toilet bowl water and using them to wipe other surfaces.
High-touch surfaces including call lights, bed controls, light switches, and door handles were not cleaned during routine cleaning, only during deep cleaning or discharge cleaning. This practice contradicts infection control standards that require daily disinfection of frequently touched surfaces.
The facility's housekeeping manager acknowledged that high-touch surfaces should be cleaned daily with proper dwell times for disinfectants to be effective, indicating awareness of proper procedures but failure in implementation.
Training Deficiencies Create Safety Risks
The inspection revealed significant gaps in required staff training. Seventeen of 74 staff members had not completed annual abuse prevention training, and 15 staff members lacked current dementia management training. The director of nursing, who had been in her position for only six weeks, could not explain why the training requirements had not been met.
Federal regulations require facilities to educate staff on activities that constitute abuse, neglect, and exploitation; procedures for reporting incidents; and dementia care approaches. These training requirements are designed to protect vulnerable residents and ensure appropriate care responses.
Regulatory Response and Standards
The violations were classified as causing minimal harm or potential for actual harm, with some affecting multiple residents throughout the facility. Federal standards require nursing homes to provide appropriate mental health services, follow therapeutic diets as prescribed, maintain infection control programs, and ensure all staff receive required training.
Mental health services in nursing facilities must address residents' psychological needs and include monitoring for residents with trauma histories or mental health diagnoses. Dietary services must accurately provide prescribed therapeutic diets to support medical treatment. Infection control programs must prevent disease transmission through proper PPE use and environmental cleaning.
The facility must develop and implement corrective action plans to address each violation area and demonstrate sustained compliance with federal requirements to avoid potential enforcement actions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood Post Acute and Rehabilitation from 2025-03-27 including all violations, facility responses, and corrective action plans.
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