Sierra Post Acute

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

spiritual wellbeing related to transportation accident. Interventions included allowing him time to make choices in care and encourage active decision making, approaching the resident in a calm, reassuring manner, encouraging the resident to verbalize his feelings, encouraging the resident to participate in activities of choice, monitoring for signs/symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report abnormal findings to physician. A nurses note, dated 1/5/25 at 2:37 p.m., documented the nurse was notified by a CNA that Resident #32 admitted to hitting Resident #21 two to three times in the head while he was sleeping in bed. The CNAs separated the residents and put them on frequent checks. When the nurse assessed Resident #21 he denied any pain or loss of consciousness. Resident #21 was asked if he was in fear and he stated no and said his roommate just went crazy. The doctor was notified of the incident and Resident #21's guardian attempted to be notified but his voicemail was full and was unable to leave a message at the time. IV. Staff interviewsCNA #9 was interviewed on 1/28/26 at approximately 10:05 a.m. CNA #9 said Resident #32 was easily agitated. CNA #9 said Resident #32 was involved in a resident-to-resident altercation two to three weeks ago, when he punched his roommate. CNA #9 said the altercation was not observed. She said Resident #32 reported it himself. CNA #9 said Resident #21 was moved into a different room after the 1/5/26 altercation occurred.

CNA #9 said Resident #32 was moved into a different room approximately one week prior, however he was unsure why. Registered nurse (RN) #2 was interviewed on 1/28/26 at 2:01 p.m. RN #2 said Resident #32 was initially placed on one-to-one observations after the altercation occurred. RN #2 said the resident was recently moved into a separate room as an intervention for the altercation. RN #2 said she was unsure why there was a delay in the room change occurring. RN #2 said Resident #32's triggers included hearing voices related to his medical condition. RN #2 said facility management would come onto the unit and alert staff of any changed care plan interventions. RN #2 said care interventions could be found in the resident's care plan or on the 24 hour nurse report sheets. RN #2 said updating the resident's care plan timely was important for resident safety and continuity of care. The social services director (SSD) was interviewed on 1/29/26 at 1:49 p.m. The SSD said Resident #32 stated he hit Resident #21 due to uncontrollable anger that came up. The SSD said Resident #32 did have a history of resident-to-resident altercations. She said in

the past, the reported root cause was his auditory hallucinations. The SSD said moving Resident #32 to a different room was delayed due to a different resident occupying it, and the facility needed to provide a five day room change notification. The SSD said the social services team was responsible for managing the resident's behavior care plans. The NHA was interviewed on 1/29/26 at 3:09 p.m. The NHA said Resident #32 participated in facility activities and received frequent visits from social services. The NHA said he was unable to state what interventions were put in place to manage Resident #32's anger related outbursts after

the resident-to-resident altercation on 1/5/26.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sierra Post Acute

1432 Depew St Lakewood, CO 80214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

room move was permanent or why his personal belongings were still in his old room. LPN #3 said she located the resident's scrum cap on the dresser and his hipsters in the drawer along with his personal belongings in his old room. -The facility failed to ensure fall interventions were consistently in place. The director of nursing (DON) was interviewed on 1/29/26 at 12:23 p.m. She said the staff could review the resident's care plan or Kardex (staff directive tool) for care needs and interventions needed for keeping residents safe. The DON said if they had any new interventions, there was a binder at each nurses' station to help the staff learn about new interventions put in place for residents. The DON went to the memory care unit and observed Resident #10's current room. She said the resident's room move was permanent and was not sure why his personal belongings were not moved to his new room since it had been over a week since the move. The DON said fall interventions should be used at all times in order to keep residents safe.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sierra Post Acute

1432 Depew St Lakewood, CO 80214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

She washed the supra pubic area. She then grabbed a second clean washcloth and cleaned the area a second time. She grabbed a clean washcloth, placed it in the warm water, and rinsed the area. She grabbed a clean washcloth and dried the area. She placed a new drain sponge on the supra pubic catheter site. She reattached the secure tabs of his adult disposable brief. She took off her PPE and disposed of it.

She washed her hands, and she put on gloves, and grabbed the garbage bag from the resident's waste basket, along with PPE and an old Foley catheter bag, to take to the garbage disposal area. -The IP failed to change her gloves and perform hand hygiene after removing the soiled drain sponge. And failed to place the old Foley catheter bag in a red bag for bodily fluids.

C. Staff interviews

The IP was interviewed on 1/28/26 at 2:30 p.m. The IP said she did not normally perform supra pubic catheter care. She said the nurse assigned to the resident was having an issue with the catheter care and asked her to complete the care. She said gloves should be changed after removing the dirty dressing.

The DON was interviewed on 1/28/26 at 2:50 p.m. The DON said the nurse should remove the old dressing, remove gloves, wash hands and place clean gloves on to complete the Foley catheter care. She said the nurse should place the dirty Foley catheter bag into a red biohazard bag to discard it.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet