Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeside Post Acute during CMS and state inspections, most recent first.
A resident with bipolar disorder, PTSD, traumatic brain injury, and moderate cognitive impairment alleged that an LPN and CNA were rough and sexually abusive during incontinence care, stating the LPN aggressively rolled him, caused his head to hit the wall, and repeatedly inserted a finger into his anus despite his protests. The facility’s investigation relied on staff statements and lack of observed rectal trauma, did not interview the roommate, and did not explore why staff continued care after the resident’s abuse allegation. The resident also reported ongoing rough transfers, inadequate repositioning in a wheelchair causing pain and bruising, and lack of assistance with proper positioning for meals, which was corroborated by observation of poor positioning, a bruise on his arm, and food spilled on his shirt. Although the care plan noted a history of false allegations and required care in pairs and investigation of voiced concerns, it lacked a specific focus on the resident’s PTSD and did not address his repeated reports that staff’s incontinence care and handling were rough and abusive.
Two residents engaged in a verbal and physical altercation in the smoking area, resulting in one resident being struck, scratched, and burned with a cigarette. No staff were present during the incident, and another resident had to seek help. The affected resident had a history of depression, anxiety, and paraplegia, while the other had a care plan for potential aggression. The facility's lack of supervision and incomplete witness interviews contributed to the substantiated abuse.
A resident with a history of mental illness and substance dependence eloped twice from a facility due to inadequate supervision. Initially deemed not at risk for elopement, the resident left unsupervised when a receptionist failed to notice her following another person out. Despite being placed on 15-minute checks, the resident eloped again the same day when a nurse buzzed her out without checking the camera. The resident was found 29 hours later and taken to the hospital per the guardian's request.
A resident with multiple medical conditions was improperly discharged AMA from a facility without adequate documentation or notification to their legal representative. The facility relied on a behavioral contract for the discharge, failing to document unmet needs or notify relevant agencies. The NHA admitted to not following proper procedures, contributing to the deficiency.
Two residents in a facility experienced significant medication errors. One resident, with schizoaffective disorder and bipolar disorder, missed doses of clozapine due to the facility's failure to send necessary lab results to the pharmacy, resulting in self-harm. Another resident received an incorrect dosage of an antibiotic for nearly a year due to a failure in updating medication orders after a physician's recommendation. The facility did not follow its policy on medication shortages and failed to conduct proper medication reconciliation.
The facility failed to properly store and label beverages, air-dry cooking utensils, discard dented cans, and use correct sanitizing test strips. Observations showed undated beverages in unit refrigerators, moisture between stacked pans, dented cans stored with other goods, and incorrect sanitizing solution testing. Staff interviews confirmed these deficiencies, highlighting risks of food-borne illnesses and cross-contamination.
The facility failed to maintain an effective infection control program, with deficiencies observed in housekeeping and wound care practices. Housekeeping staff did not properly disinfect high-touch surfaces, and wound care procedures lacked adherence to infection control protocols. An LPN and an RN were observed failing to maintain clean working areas and perform necessary hand hygiene, increasing the risk of infection transmission.
The facility failed to maintain a safe and functional environment, with issues such as a cracked entrance walkway, non-functional handicapped door opener, and cluttered hallways. Common areas were obstructed by debris and equipment, posing trip hazards. Residents and staff reported ongoing maintenance issues, with the maintenance director acknowledging a backlog of repairs.
A resident in an LTC facility, who was cognitively intact and required assistance with mobility and dressing, reported that staff frequently entered her room without respecting her privacy. During an observation, an activities assistant entered the resident's room without knocking while personal care was being provided, which upset the resident. The assistant was aware of the facility's policy to knock before entering but failed to do so, citing previous complaints from the resident about loud knocking disturbing her sleep.
A facility failed to update a care plan for a resident with confrontational behaviors. Despite being cognitively intact, the resident exhibited behaviors that led to a police intervention. The care plan, last revised in February, did not include interventions for these behaviors. Staff interviews confirmed the resident's tendency to initiate confrontations, and the DON acknowledged the need for an updated care plan.
A resident, who was an unsupervised smoker, repeatedly smoked in an undesignated area at the front of the facility, contrary to the facility's smoking policy. This area lacked proper disposal for cigarette butts and posed a fire hazard due to a nearby wooden fence. Staff were aware of the resident's actions but were unsure who permitted it, while the NHA acknowledged allowing the resident to smoke there.
A resident receiving dialysis care did not have their pre-dialysis assessment section consistently completed on communication forms, as required by facility policy. Despite being scheduled for dialysis three times a week, the forms were not filled out on several occasions, leading to incomplete communication with the dialysis center. Staff interviews revealed lapses in responsibility for completing these forms.
A resident in a LTC facility did not receive timely dental services after losing his dentures, affecting his ability to eat. Despite a dentist's recommendation for new dentures months prior, the facility failed to schedule follow-up appointments or document actions taken. Staff interviews revealed awareness of the issue, but no steps were documented to address the resident's dental needs, resulting in a deficiency.
Failure to Thoroughly Investigate and Address Allegations of Sexual and Rough, Abusive Care
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document allegations of sexual abuse and rough, abusive care toward a resident. The facility’s abuse policy required that all reports of resident abuse be thoroughly investigated and documented. An investigation dated 2/24/26 addressed an allegation that a resident was sexually abused during incontinence care, but the investigation did not include interviewing the resident’s roommate about what he might have seen or heard during the alleged incident. The investigation concluded the allegation was unsubstantiated based on lack of physical trauma and staff statements, and it attributed the resident’s report to cognitive decline and terminal agitation, despite the resident’s clear and consistent account during the survey interview. The resident involved was under age 65 with diagnoses including bipolar disorder, anxiety, depression, PTSD, and traumatic brain injury. A recent MDS showed moderate cognitive impairment (BIMS 12/15), aggressive behavior, and delusions, and the resident was dependent on staff for toileting, transfers, and bed mobility, using a manual wheelchair. During the facility’s investigation, the resident reported that while yelling for help after a bowel movement, a CNA entered and began care, and then an LPN took over. The resident stated he did not want the LPN to provide care, tried to swat him away, and that the LPN grabbed his hands, rolled him aggressively causing his head to hit the wall, and inserted a finger into his anus four times while wiping, despite the resident yelling for him to stop. Staff statements conflicted with the resident’s account regarding who provided care and what occurred, and the facility did not investigate why staff did not stop care and have another staff member take over when the resident alleged abuse during the episode. The resident continued to report that staff were rough and that their approach to care felt abusive, including prior rough transfers by the same LPN and improper positioning and repositioning by other staff that caused pain and bruising. On the survey date, the resident described ongoing rough care, lack of staff responsiveness to his requests, and feeling that no one listened to or believed him. He reported that staff did not assist him to sit up properly for breakfast, resulting in difficulty eating and spilled food on his shirt. Observation during the interview showed the resident slouched and slumped to the left in his wheelchair, with his left arm hanging over the side, a bruise on his upper arm where the armrest was pressing, and dried oatmeal on his shirt from the morning meal. The resident’s care plan documented a history of false allegations and required care in pairs, investigation of all concerns voiced, and a calm, slow approach, but there was no specific care plan focus addressing his PTSD or his allegations of rough or abusive incontinence care, and the facility did not pursue his ongoing reports of rough and abusive treatment during personal care.
Failure to Prevent Resident-to-Resident Physical Abuse in Smoking Area
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident in the smoking patio area. During the incident, a verbal altercation escalated when one resident made inappropriate comments and moved his electric wheelchair toward the other, who responded by flicking a lit cigarette, spitting, grabbing the resident's arm, digging fingernails into the skin, and striking the resident in the face, causing his glasses to fall. There were no staff members present during the altercation, and another resident had to leave the area to get help. The initial assessment by a registered nurse documented minor scratches and a small burn, which the resident declined treatment for at the time. A subsequent assessment noted a burn mark consistent with a cigarette burn that was not initially observed. The resident who was the victim of the abuse had a history of depression, anxiety, and paraplegia, requiring substantial assistance with activities of daily living. His care plan included interventions for verbal aggression and agitation, but there was no indication of behaviors that would have predicted the escalation to physical abuse. The assailant, also cognitively intact, had a care plan noting a potential for anger and aggression if provoked, with interventions for monitoring and de-escalation. However, staff interviews indicated that neither resident was known for physical aggression, and the incident was unexpected by those familiar with their behaviors. The facility's policy required supervision and interventions to prevent abuse, but at the time of the incident, there was no staff supervision in the smoking area, and the camera in that area was not functioning. Witness interviews revealed that not all potential witnesses were interviewed as part of the investigation. The lack of staff presence and incomplete witness interviews contributed to the failure to prevent and fully investigate the abuse incident, resulting in a substantiated finding of resident-to-resident physical abuse.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and facility-assisted devices to prevent the elopement of a resident diagnosed with bipolar disorder, adult failure to thrive, cocaine dependence, and alcohol dependence. Upon admission, the resident was evaluated and deemed not at risk for elopement or wandering. However, the resident had an emergency court-appointed guardian who requested that the resident not leave the facility without supervision due to her mental illness and substance-seeking behaviors. On the morning of January 10, 2025, the resident left the facility unsupervised when a receptionist buzzed someone out the front door and failed to notice the resident following behind. The resident was located over two hours later by the guardian near a homeless shelter approximately five miles from the facility. Despite being placed on 15-minute checks upon her return, the intervention proved ineffective as the resident eloped a second time the same day. This occurred when a nurse buzzed the resident out the facility door without checking the camera to see who was being buzzed out. The second elopement resulted in the resident being missing for almost 29 hours before being found by a staff member on the side of the road in a downtown area. The staff member notified the nursing home administrator and the police, who then transported the resident to the hospital per the guardian's request. The facility's failure to ensure staff were aware of which residents required supervision when leaving the facility led to these incidents, creating a situation with the likelihood of serious harm to the resident's health and safety.
Improper Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a proper discharge process for a resident, leading to a deficiency in discharge planning. The resident, who was under 65 years old and had multiple medical conditions including end-stage renal disease and hypertension, was discharged against medical advice (AMA) without adequate documentation or notification to the resident's legal representative. The facility's policy required that residents not be discharged without a valid reason and that they be informed of their rights, including the right to appeal. However, the facility did not adhere to these policies in the case of this resident. The resident had a history of leaving the facility and not returning as scheduled, which led to the signing of a behavioral contract. This contract stipulated that if the resident did not return on time, they would be discharged AMA. On one occasion, the resident left the facility with medications for an overnight pass but did not return as expected. The facility attempted to contact the resident but ultimately discharged them AMA when they did not return by the agreed time. The facility did not document the resident's unmet needs or attempts to meet those needs, nor did they notify the ombudsman or state agencies, as they believed the discharge was AMA. Interviews with the nursing home administrator (NHA) revealed a lack of understanding of the proper discharge procedures. The NHA admitted to not documenting critical information, such as the resident's medication status or the conversation about the discharge. The NHA also acknowledged that the facility did not offer to retrieve the resident or provide their medications post-discharge. The failure to follow proper discharge protocols and the reliance on a behavioral contract as a basis for discharge contributed to the deficiency identified in the survey.
Medication Errors Lead to Resident Harm and Incorrect Dosage Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #4, diagnosed with schizoaffective disorder and bipolar disorder, did not receive her prescribed antipsychotic medication, clozapine, for two consecutive days. This occurred because the facility did not send the required complete blood count (CBC) laboratory results to the pharmacy, which was necessary for the medication refill. As a result, Resident #4 experienced increased anxiety and self-harmed by burning her forearm with a cigarette, leading to blisters that required medical attention. The facility's policy on medication shortages and unavailability was not followed. Staff failed to notify the attending physician or the nursing supervisor about the medication unavailability and did not document the missed doses in the resident's medical records. Interviews with the nursing staff revealed a lack of communication and documentation regarding the medication shortage, contributing to the significant medication error. Resident #38 was also affected by a medication error. The facility did not update the resident's antibiotic medication order following an infectious disease physician's recommendation to reduce the dosage. Consequently, the resident received an incorrect dosage of the antibiotic cephalexin for nearly a year. The facility failed to conduct a medication review and reconciliation after the resident's appointment with the infectious disease physician, and there was no documentation of an individualized care plan for antibiotic stewardship and infection monitoring.
Deficiencies in Food Storage, Preparation, and Sanitization
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices in its unit refrigerators. Observations revealed that beverages, including milk and juice, were not dated or labeled, which is against the Colorado Retail Food Establishment Rules and Regulations. Interviews with the dietary manager and a licensed practical nurse confirmed that nursing staff were responsible for labeling and dating opened items, and the lack of proper labeling could lead to food-borne illnesses. In the main kitchen, the facility did not adhere to proper drying procedures for cooking utensils and pans. Observations showed that metal pans were stacked with moisture between them, contrary to the facility's Kitchen Sanitation policy and state regulations that require air-drying to prevent cross-contamination. Interviews with dietary staff indicated a lack of adherence to these procedures, which could attract harmful bacteria. The facility also failed to discard dented food cans, which were found during a kitchen tour. According to USDA guidelines, dented cans can harbor dangerous bacteria, yet they were stored with other canned goods. Additionally, the facility used incorrect test strips for sanitizing solutions, leading to inaccurate concentration levels. The dietary manager acknowledged the use of wrong test strips and the absence of proper documentation for sanitizing solution testing, which is crucial for maintaining hygiene standards.
Infection Control Deficiencies in Housekeeping and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed in housekeeping and wound care practices. Housekeeping staff did not adhere to proper cleaning techniques, particularly in disinfecting high-touch surfaces in resident rooms. Observations revealed that housekeepers used a Swiffer duster instead of disinfectant solutions on high-touch areas such as call lights, bed controls, and light switches. Additionally, the cleaning process did not follow the recommended sequence from cleanest to dirtiest areas, leading to potential cross-contamination. In the area of wound care, the facility's staff did not follow infection control protocols during and after wound care procedures. An LPN was observed providing wound care in a shower room without establishing a clean working area for supplies and treatment. The LPN failed to perform hand hygiene between glove changes and did not place a barrier pad under the resident's leg, resulting in wound drainage contaminating the floor and wheelchair foot pedals. Furthermore, the LPN did not clean the shower room floor or the resident's foot pedals after the procedure, increasing the risk of infection transmission. Another incident involved an RN providing wound care to a resident in their room. The RN did not replace a soiled chucks barrier pad or incontinence brief before changing the wound dressing, compromising the cleanliness of the working area. The RN also failed to provide a clean surface for the wound care supplies, which could lead to contamination. These actions demonstrate a lack of adherence to established infection control policies and procedures, contributing to the facility's failure to prevent the spread of infection.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed significant issues with the physical environment, including a cracked and uneven main entrance walkway, cluttered hallways, and missing light covers. The front concrete sidewalk had a large hole, causing difficulties for residents and visitors, particularly those using wheelchairs. Additionally, the handicapped door opener was non-functional, creating accessibility challenges for residents. The facility's common areas and recreational spaces were not adequately maintained. Sidewalks and patios were cluttered with debris, hoses, and disassembled equipment, posing trip hazards. The recreation room was obstructed by an extension cord, limiting access to amenities. The flooring outside the rehabilitation gym was uneven, with gaps that could cause trips, especially for residents with mobility aids. The back parking lot was used as a dumping ground for broken equipment and trash, visible from inside the facility, and the landscaping was overgrown with weeds. Interviews with residents and staff highlighted ongoing issues with maintenance and repairs. Residents expressed concerns about the long-standing disrepair of the entrance sidewalk and the broken handicapped door opener. The maintenance director acknowledged the backlog of repairs and the need for a dumpster to clear the accumulated junk. The nursing home administrator was aware of the maintenance challenges but had not yet addressed the specific issues raised in the report.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during personal care, as observed in the case of a resident who was cognitively intact and required assistance with mobility and dressing. The resident expressed concerns about staff frequently entering her room without respecting her privacy, particularly during personal care. On one occasion, a certified nurse aide (CNA) knocked and entered the room appropriately, but an activities assistant (AA) entered without knocking while personal care was being provided, which upset the resident. The activities assistant, who had been in her position for two months, admitted to not knocking before entering the room, despite being aware of the facility's policy to knock and wait for a response. The assistant mentioned that the resident had previously complained about loud knocking disturbing her sleep, but this concern was not documented or reported. The nursing home administrator confirmed the facility's policy of respecting residents' rights to privacy and dignity, emphasizing the importance of knocking before entering a resident's room.
Failure to Update Care Plan for Resident's Confrontational Behaviors
Penalty
Summary
The facility failed to develop and revise a comprehensive care plan for a resident with confrontational behaviors. The resident, under 65 years old, was admitted with diagnoses including chronic respiratory failure, chronic pain syndrome, bipolar disorder, major depressive disorder, and diabetes mellitus. Despite being cognitively intact, the resident exhibited confrontational behaviors, as documented in a nursing progress note. The note detailed an incident where the resident was found in another resident's space, yelling and using foul language, which escalated to the involvement of law enforcement. However, the resident's care plan, which was last revised in February 2023, did not include interventions to address these behaviors. Interviews with facility staff, including an LPN and the DON, confirmed the resident's tendency to initiate confrontations and use accusatory language. The DON acknowledged that the care plan should have been updated following the incident to include strategies for managing the resident's escalating behaviors. The NHA also recognized the need for a care plan with person-centered approaches to address the resident's confrontational behaviors, indicating a lapse in updating the care plan to reflect the resident's current needs.
Resident Smoking in Undesignated Area Creates Fire Hazard
Penalty
Summary
The facility failed to ensure that a resident, who was an unsupervised smoker, adhered to the designated smoking areas as per the facility's smoking policy. The resident, who was cognitively intact and required moderate assistance with personal care, was observed multiple times smoking in an area that was not designated for smoking. This area was located at the front of the facility, where the resident extinguished cigarettes on the ground and discarded the butts between a concrete slab and a wooden fence, creating a potential fire hazard. Staff interviews revealed that both a CNA and an RN were aware of the resident's smoking habits in the undesignated area but were unsure who permitted it. The NHA acknowledged allowing the resident to smoke in the undesignated area and recognized the potential fire hazard due to the lack of an ashtray and the presence of a wooden fence. Despite the facility's policy, the resident continued to smoke in the undesignated area, leading to a deficiency in maintaining a safe environment free from accident hazards.
Incomplete Pre-Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care was provided with services consistent with professional standards of practice. Specifically, the facility did not consistently complete the pre-dialysis assessment section on the dialysis communication forms for the resident. The facility's policy required that nursing staff send a dialysis communication to the dialysis center every time a resident was scheduled for dialysis, which was not adhered to in this case. The resident, who was cognitively intact and had diagnoses including end-stage renal disease, was scheduled for dialysis three times a week. However, the pre-dialysis section of the communication forms was not completed on multiple occasions, as observed in the resident's records from May to July 2024. Interviews with staff revealed that the responsibility for completing these forms was not consistently fulfilled, with LPNs and the DON acknowledging lapses in the process. This lack of adherence to protocol resulted in incomplete communication with the dialysis center regarding the resident's pre-dialysis status.
Failure to Provide Timely Dental Services for Resident
Penalty
Summary
The facility failed to provide timely dental services for a resident who required new dentures. The resident, who was cognitively intact and independent in oral hygiene and eating, reported that his dentures went missing a few months ago, which affected his ability to eat certain foods. Despite the resident's report and the dentist's recommendation for new dentures made in October 2023, the facility did not schedule any follow-up appointments or document any actions taken to address the resident's dental needs. The facility's policy required referral for dental services within three days for lost or damaged dentures, but this was not adhered to in this case. Interviews with staff revealed that the social service director was aware of the missing dentures, and there was an assumption that the facility was waiting for insurance approval. However, there was no documentation to support this, and the nursing home administrator confirmed that no steps had been taken to obtain new dentures for the resident. The resident's medical record lacked documentation of coordinated care for dental services, and the facility did not ensure the resident received the necessary dental care, resulting in a deficiency in providing routine and emergency dental services.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wheat Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehabilitation Center At Sandalwood, The | 0.5 mi | ★★★★★ | 7 | 0 |
| Wheatridge Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Cambridge Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.9 mi | ★★★★★ | 14 | 0 |
| Harmony Pointe Care Center | 1.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.