Sierra Post Acute: Safety Hazard Causes Resident Harm - CO
The infection preventionist was performing catheter care on a resident when inspectors observed the violations on January 28. She washed the catheter area twice with clean washcloths, rinsed and dried it, then placed a new drain sponge on the catheter site. She reattached the resident's adult brief, removed her protective equipment, and washed her hands.
But inspectors noted critical lapses. She failed to change her gloves after removing the soiled drain sponge. She also failed to perform hand hygiene at that step.
The nurse then put on gloves and collected garbage from the resident's room, including protective equipment and an old catheter bag. She disposed of the catheter bag in regular waste instead of placing it in a red biohazard bag for bodily fluids.
When interviewed, the infection preventionist admitted she didn't normally perform catheter care. She said the nurse assigned to the resident was having trouble with the procedure and asked her to complete it. She acknowledged that gloves should be changed after removing dirty dressings.
The director of nursing confirmed proper protocol during her interview. She said nurses should remove old dressings, 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. Improper infection control during catheter care can spread bacteria and other pathogens throughout a facility, particularly dangerous for vulnerable nursing home residents with compromised immune systems.
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 21, 2026 · Our methodology
SIERRA POST ACUTE in LAKEWOOD, CO was cited for violations during a health inspection on January 29, 2026.
The infection preventionist was performing catheter care on a resident when inspectors observed the violations 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.