Sierra Post Acute
SIERRA POST ACUTE in LAKEWOOD, CO — inspection on January 29, 2026.
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
while he was sleeping in bed.
The CNAs separated the residents and put them on frequent checks.
notified of the incident and Resident #21's guardian attempted to be notified but his voicemail was full
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.
065272 01/29/2026
Sierra Post Acute 1432 Depew St Lakewood, CO 80214
was not sure why his personal belongings were not moved to his new room since it had been over a
residents safe.
065272 01/29/2026
Sierra Post Acute 1432 Depew St Lakewood, CO 80214
second time.
She grabbed a clean washcloth, placed it in the warm water, and rinsed the area.
She
disposed of it.
She washed her hands, and she put on gloves, and grabbed the garbage bag from the
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.