Sierra Post Acute: Abuse Protection Failures - CO
Federal inspectors observed the infection preventionist performing suprapubic catheter care on January 28. The nurse washed the catheter site area twice with clean washcloths, rinsed and dried the area, then placed a new drain sponge on the catheter site before reattaching the resident's adult brief.
But the nurse made critical errors. After removing the soiled drain sponge, she failed to change her gloves before continuing the procedure. She also disposed of an old Foley catheter bag in regular garbage instead of placing it in a red biohazard bag designated for bodily fluids.
The infection preventionist told inspectors she didn't normally perform suprapubic catheter care. The regular nurse assigned to the resident was having difficulty with the catheter care and asked her to complete it instead.
When questioned, the nurse acknowledged her mistakes. She said gloves should be changed after removing the dirty dressing.
The Director of Nursing confirmed the proper protocol during her interview. She explained that nurses should remove the old dressing, remove gloves, wash hands, and put on clean gloves before completing catheter care. Dirty catheter bags must go into red biohazard bags for disposal.
The violations affected many residents according to the inspection report, as contaminated gloves could spread infection throughout the facility. Federal inspectors classified the harm level as minimal but noted the potential for actual harm to residents.
The facility's infection control failures came to light during a complaint investigation completed January 29.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sierra Post Acute from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SIERRA POST ACUTE in LAKEWOOD, CO was cited for abuse-related violations during a health inspection on January 29, 2026.
Federal inspectors observed the infection preventionist performing suprapubic catheter care on January 28.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.