Inspection Reports for
Lakewood Post Acute and Rehabilitation
7395 W EASTMAN PL, LAKEWOOD, CO, 80227-5006
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with therapeutic diet orders and ensure residents received foods in the appropriate form as prescribed by the physician and assessed by the interdisciplinary team.
Findings
The facility failed to consistently follow the physician's order for a renal diet for Resident #5, who received foods high in potassium such as potatoes, tomatoes, and bananas, contrary to her prescribed renal diet. The nutrition service manager acknowledged occasional errors in the electronic ticket system used for meal orders and planned to improve accuracy and staff education.
Deficiencies (1)
Failure to ensure therapeutic diets were prescribed and followed, specifically the renal diet for Resident #5.
Report Facts
Weight loss percentage: 4
Protein diet grams: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nutrition Service Manager | Interviewed regarding errors in the electronic ticket system and plans to improve accuracy and education. | |
| Registered Dietitian | Interviewed about reviewing and entering the resident's prescribed diet and checking meal tickets for accuracy. |
Inspection Report
Routine
Deficiencies: 11
Date: Mar 27, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, care planning, infection control, staff training, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications prior to administration, incomplete and inadequate care plans for residents, lack of physician orders for oxygen therapy and specialized medical devices, failure to provide appropriate dialysis communication, incomplete annual performance reviews and training for staff, inadequate mental health services and monitoring for residents with psychosocial needs, failure to document and justify use of psychotropic medications and non-pharmacological interventions, failure to consistently follow therapeutic diet orders, and deficiencies in infection control practices including improper use of PPE and inadequate cleaning and disinfection procedures.
Deficiencies (11)
Failed to ensure informed consent was obtained for psychotropic medication prior to administration for Resident #4.
Failed to develop and implement comprehensive care plans addressing all resident needs including use of oxygen and splints for Residents #18 and #15.
Failed to ensure residents had physician orders for specialized medical devices for Resident #15.
Failed to ensure Resident #18 had a physician's order for oxygen therapy and ensure portable oxygen tank was operating when in use.
Failed to consistently complete the post-dialysis section of dialysis communication forms for Resident #75.
Failed to complete annual performance reviews and provide regular in-service education for five certified nurse aides.
Failed to provide appropriate treatment and services for Resident #78 with mental disorder and psychosocial adjustment difficulty, including monitoring for suicidal ideation and providing mental health services.
Failed to ensure Residents #15 and #11 were free from unnecessary psychotropic medications by not documenting behaviors, care plan approaches, and non-pharmacological interventions prior to medication use.
Failed to ensure Resident #5 received foods consistent with prescribed renal diet and failed to specify therapeutic diet in care plan.
Failed to maintain infection control program including proper use of PPE in isolation rooms, proper cleaning by housekeeping staff, and adherence to disinfectant dwell times.
Failed to provide annual abuse and dementia training to all staff members.
Report Facts
Residents reviewed: 17
Staff members without annual abuse training: 17
Staff members without annual dementia training: 15
PRN Valium administrations: 107
PRN Valium administrations without documented non-pharmacological intervention: 82
Dialysis sessions: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #1 | LPN | Interviewed regarding informed consent, psychotropic medication use, and non-pharmacological interventions. |
| Social service director | SSD | Interviewed regarding informed consent, mental health services, psychotropic medication monitoring, and trauma assessments. |
| Director of nursing | DON | Interviewed regarding consent processes, care plans, oxygen therapy, staff training, and psychotherapeutic drug meetings. |
| Assistant director of nursing | ADON | Interviewed regarding oxygen therapy care plans and orders, dialysis communication, and staff responsibilities. |
| Registered nurse #1 | RN | Interviewed regarding oxygen therapy, dialysis communication, and infection control practices. |
| Certified nurse aide #2 | CNA | Interviewed regarding resident behaviors and non-pharmacological interventions. |
| Housekeeping laundry manager | HLM | Interviewed regarding cleaning procedures, disinfectant use, and infection control. |
| Housekeeper #1 | HK | Observed and interviewed regarding cleaning practices and disinfectant use. |
| Infection preventionist | IP | Interviewed regarding infection control policies and PPE use. |
| Nutrition service manager | NSM | Interviewed regarding dietary orders and meal ticket system. |
| Registered dietitian | RD | Interviewed regarding dietary assessments and meal ticket system. |
| Unidentified oxygen supplier | Observed and interviewed regarding PPE use in isolation rooms. |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 28, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, medication management, infection control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to formulate advance directives, incomplete care plans, medication administration errors, inadequate pain management, improper infection control practices, failure to maintain proper food safety standards, and lack of staff competency evaluations.
Deficiencies (13)
Failed to ensure residents' rights to formulate advance directives were honored, including mismatches between physician orders and advance directive forms for multiple residents.
Failed to develop comprehensive care plans with measurable objectives and timeframes for residents, including catheter care and medication use.
Failed to provide services meeting professional standards, including failure to document and administer pain medications timely and accurately.
Failed to ensure medication administration was documented immediately and accurately, including narcotic medications.
Failed to provide adequate nutrition care, including failure to monitor and administer enteral tube feedings and supplements correctly, resulting in significant weight loss.
Failed to ensure respiratory care for a resident with tracheostomy, including lack of physician orders and baseline care plan.
Failed to provide safe and appropriate pain management, including failure to provide timely pain medication and adequate pain assessments after surgery.
Failed to ensure staff competency evaluations for certified nurse aides and licensed nurses were conducted and documented.
Failed to ensure residents were free from significant medication errors, including administration of incorrect IV antibiotics.
Failed to ensure drugs and biologicals were labeled properly and stored securely, including unlocked medication carts and unlabeled opened insulin vials.
Failed to procure, store, prepare, and serve food in a sanitary manner, including failure to monitor dish machine temperatures, improper hand hygiene during meal service, and failure to maintain proper refrigerator temperatures for perishable foods.
Failed to provide and implement an infection prevention and control program, including failure to provide isolation signage, improper use of personal protective equipment, and failure to keep isolation room doors closed.
Failed to develop and implement policies and procedures for pneumococcal vaccinations, including failure to offer vaccines upon admission and failure to offer additional doses as indicated.
Report Facts
Residents reviewed: 28
Residents affected by advance directive deficiency: 5
Residents affected by care plan deficiency: 2
Residents affected by medication documentation deficiency: 2
Residents affected by nutrition deficiency: 1
Residents affected by respiratory care deficiency: 1
Residents affected by pain management deficiency: 1
Residents affected by medication error: 1
Residents affected by infection control deficiency: 1
Residents affected by pneumococcal vaccination deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in pain management and medication administration deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and nutrition deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including pain management, medication errors, infection control, and staff competency |
| NHA | Nursing Home Administrator | Named in multiple deficiencies including infection control, medication errors, and staff competency |
| SSD | Social Services Director | Named in advance directive and medication error deficiencies |
| CNA #1 | Certified Nurse Aide | Named in infection control deficiency |
| CNA #2 | Certified Nurse Aide | Named in advance directive deficiency |
| CNA #3 | Certified Nurse Aide | Named in staff competency deficiency |
| RD #1 | Registered Dietitian | Named in nutrition deficiency |
| RD #2 | Registered Dietitian | Named in nutrition deficiency |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, specifically regarding treatment and monitoring of diabetic residents, following concerns about Resident #1's blood sugar management.
Findings
The facility failed to consistently monitor and treat Resident #1's low blood sugar as ordered, did not notify the provider of changes in condition, and discontinued blood sugar checks prematurely, resulting in actual harm to the resident who required hospital transfer.
Deficiencies (1)
Failure to consistently monitor blood sugar for Resident #1 as ordered and failure to notify the provider of changes in condition.
Report Facts
Blood sugar readings: 60
Blood sugar readings: 61
Blood sugar readings: 68
Blood sugar readings: 53
Blood sugar readings: 52
Blood sugar reading after treatment: 137
Medication order: 2
Blood sugar check frequency: 4
Vital signs check frequency: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed about facility's diabetic precautions and blood sugar monitoring | |
| Facility Medical Director | Interviewed; treating physician for Resident #1; discussed failure to notify provider | |
| Director of Nursing (DON) | Interviewed; provided facility diabetic policy; discussed plans for staff education |
Inspection Report
Routine
Deficiencies: 11
Date: Feb 25, 2020
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident dignity, medication administration, environmental safety, respiratory care, psychotropic medication use, medication storage, food safety, and skin integrity management.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, improper medication administration and monitoring, inadequate environmental maintenance, improper medication storage and labeling, failure to ensure proper respiratory care and oxygen administration, lack of appropriate psychotropic medication monitoring and care planning, poor food handling hygiene, and incomplete skin assessment documentation.
Deficiencies (11)
Failure to treat Resident #110 with dignity and respect and inadequate investigation of resident's complaint about call light response and staff communication.
Failure to have last three years of recertification survey results, complaints, and plans of correction posted in a public area accessible to residents.
Failure to maintain a sanitary, orderly, and comfortable environment including unrepaired walls, carpets, and door thresholds in multiple resident rooms and hallways.
Failure to follow physician orders for administration of anti-anxiety and pain medications for Resident #50, including administration of diazepam with oxycodone contrary to orders.
Failure to ensure tubigrips were placed on Resident #50's lower extremities as ordered.
Failure to ensure Resident #39 had physician orders and care plan for oxygen administration upon admission.
Failure to administer oxygen as ordered for Residents #50, #161, and #57, and failure to discontinue oxygen order timely for Resident #57.
Failure to identify, monitor, and care plan for resident specific targeted behaviors and side effects related to psychotropic medication use for Resident #39, including lack of documentation of non-pharmacological interventions.
Failure to date injectable medications when opened, improper labeling of insulin vial, and failure to timely remove discontinued medications from medication carts.
Failure to ensure appropriate hand hygiene by food service staff during food preparation and serving.
Failure to maintain complete and accurate medical records for Resident #57, including incomplete skin assessment documentation and failure to document skin abnormalities timely.
Report Facts
Sample residents reviewed: 27
Residents affected: 6
Residents affected: 5
Residents affected: 8
Resident rooms observed: 108
Hallways observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM #1 | Unit Manager | Involved in investigation of Resident #110 dignity complaint and call light response |
| CNA #6 | Certified Nurse Aide | Named in dignity and respect deficiency related to Resident #110 |
| NHA | Nursing Home Administrator | Interviewed regarding dignity complaint and environmental concerns |
| SSD | Social Services Director | Interviewed regarding dignity complaint and psychotropic medication monitoring |
| DON | Director of Nursing | Interviewed regarding medication administration, respiratory care, psychotropic medication, medication storage, and skin integrity |
| RN #1 | Registered Nurse | Interviewed regarding medication administration and oxygen use |
| RN #2 | Registered Nurse | Interviewed regarding oxygen use and skin assessment |
| CNA #3 | Certified Nurse Aide | Interviewed regarding tubigrip use and oxygen use |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding oxygen use |
| CNA #5 | Certified Nurse Aide | Interviewed regarding oxygen use and resident behavior |
| CNA #7 | Certified Nurse Aide | Interviewed regarding oxygen use and skin checks |
| UM #3 | Unit Manager | Interviewed regarding medication storage and skin checks |
| DM | Dietary Manager | Interviewed regarding food service hand hygiene |
| Cook #1 | Cook | Observed during food preparation with improper hand hygiene |
| Cook #3 | Cook | Observed during food preparation with improper hand hygiene |
| DA #1 | Dietary Aide | Observed during food serving with improper hand hygiene |
| DA #2 | Dietary Aide | Observed during food serving with improper hand hygiene |
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