Lakewood Post Acute And Rehabilitation
LAKEWOOD POST ACUTE AND REHABILITATION in LAKEWOOD, CO — inspection on March 27, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
According to the March 2025 computerized physician orders (CPO) diagnoses included metabolic encephalopathy, congestive heart failure (fluids overload on the heart), end stage renal disease (abnormal kidney function) and type two diabetes mellitus (abnormal glucose control).
The 3/21/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) score of ten out of 15.
The MDS assessment revealed he had renal insufficiency, renal failure, or end stage renal disease (ESRD).
B.
Record review
The dialysis communication book was provided for Resident #75 on 3/25/25 at 2:17 p.m. by registered nurse (RN) #1.
Review of the binder revealed one communication sheet, dated 3/17/25.
The post dialysis section of the form was not completed by the facility staff.
The assistant director of nursing (ADON) provided a second binder for Resident #75 on 3/25/25 at 2:58 p.m.
Review of the second binder revealed the dialysis center information with chair time, resident face sheet, medical orders for scope of treatment (MOST) form and current medication list.
Review of the communication forms in the binder revealed the following:
-The 3/17/25 communication form was placed into this binder and was l missing the post dialysis section to be completed by the facility;
-The 3/19/25 communication form did not have the post dialysis section completed by facility staff;
-The 3/21/25 communication form did not have the post dialysis section completed by facility staff; and,
-The 3/24/25 communication form did not have the post dialysis section completed by facility staff.
The March 2025 CPO revealed the following physician's orders:
Obtain vital signs pre dialysis and post dialysis every shift every Monday, Wednesday and Friday, ordered on 3/24/25.
Fill out pre/post dialysis form for dialysis Monday, Wednesday and Friday, name of dialysis center, location and chair time, ordered on 3/26/25 (during the survey).
065400
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065400 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lakewood Post Acute and Rehabilitation 7395 W Eastman Pl Lakewood, CO 80227
According to the March 2025 CPO, diagnoses included altered mental status, rheumatoid arthritis, osteoporosis, muscle weakness, chronic pain syndrome and cellulitis (infection of the skin of the right lower limb.
The 1/23/25 MDS assessment documented the resident had moderate cognitive impairments with a BIMS score of nine out of 15.
She had a functional range of motion deficit to her lower extremities.
She required a wheelchair for mobility and required maximum assistance from staff for toileting, showering, dressing, bed mobility, transfers and ambulation.
B.
Resident interview and observation
065400
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065400 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lakewood Post Acute and Rehabilitation 7395 W Eastman Pl Lakewood, CO 80227
According to the March 2025 computerized physician orders (CPO), diagnoses included multiple fractures of ribs, myocardial infarction (heart attack), diabetes, chronic kidney disease, adjustment disorder with depressed mood and compression fracture of vertebra.
The 3/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.
The resident's depression screen assessment, dated 3/25/25, revealed Resident #78had indicated she felt depressed, hopeless and bad about herself.
B.
Resident interview and observation
Resident #78 was interviewed on 3/24/25 at 11:00 a.m. Resident #78 said she was recently admitted to the facility following a car accident.
She said she had asked the social services director (SSD) if she could see a therapist because she felt she needed to talk to someone. Resident #78 said she had lost her mother a few months prior to her admission to the facility, the anniversary of her nephew's murder was coming up in a few days and she was worried she would no longer be able to care for herself without assistance.
She said she had not heard anything from the SSD about a therapist appointment.
During the interview, Resident #78 became tearful and cried frequently when discussing her traumatic experiences.
065400
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065400 B.
Wing 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Lakewood Post Acute and Rehabilitation 7395 W Eastman Pl Lakewood, CO 80227