Sierra Post Acute: Infection Control Failures - CO
The infection control violation occurred during care of a resident with a suprapubic catheter. The nurse 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 personal protective equipment, and washed her hands.
But inspectors documented a critical lapse in infection control protocol. The nurse grabbed contaminated waste including an old Foley catheter bag without changing gloves or performing hand hygiene after removing the soiled drain sponge.
The nurse also failed to place the old catheter bag in a red biohazard bag as required for disposal of items containing bodily fluids.
When interviewed, the nurse told inspectors she did not normally perform suprapubic catheter care. She said another nurse assigned to the resident was having difficulty with the catheter care 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 told inspectors nurses should remove old dressings, remove gloves, wash hands, and put on clean gloves to complete catheter care. She said dirty catheter bags must go into red biohazard bags for disposal.
The violation affected many residents, according to the inspection report. Federal inspectors classified it as minimal harm or potential for actual harm.
The complaint inspection was completed January 29, 2026.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
SIERRA POST ACUTE in LAKEWOOD, CO was cited for violations during a health inspection on January 29, 2026.
The infection control violation occurred during care of a resident with a suprapubic catheter.
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.