Denver, CO

Westwood Post Acute

2-star overall rating with 1-star inspections with Special Focus status with $65,470 in total fines with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle

3185 W Arkansas Ave, Denver, CO

(303) 922-1169

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

1990-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.65

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.18

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.26

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.70

CMS adjusted RN staffing hours

Adjusted total hours

3.93

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

55%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,095

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

13.91

Composite VBP score used to determine payment impact.

Payment multiplier

0.9813

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 57.81% · Performance 72.22% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.78

Baseline 3.78 hours · Performance 3.87 hours · Measure score 2.78 · Achievement 2.78 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 34
Staff flu vaccination coverage	68.22%	42% 26.2 pts better	Numerator 73 · Denominator 107
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.2%	93.5% 5.3 pts worse	93.4% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 73.3% · Q2 84.5% · Q3 94.7% · Q4 100.0% · 4Q avg 88.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.7% 5.3 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.4% 2.6 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	7.4% 7.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	4.6%	5.0% 0.4 pts better	5.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.0% · Q3 5.8% · Q4 7.1% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.3%	11.2% 0.1 pts worse	19.6% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.0% · Q3 9.6% · Q4 10.5% · 4Q avg 11.3%
Percentage of long-stay residents who received an antipsychotic medication	21.9%	20.6% 1.3 pts worse	16.7% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 16.7% · Q3 22.6% · Q4 30.3% · 4Q avg 21.9% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	7.7%	15.2% 7.5 pts better	16.3% 8.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q3 11.7% · Q4 4.7% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	14.4%	14.6% 0.2 pts better	14.9% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 13.0% · Q3 27.9% · Q4 6.0% · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.8% 0.4 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.7%	1.5% 0.2 pts worse	1.7% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 1.8% · Q4 1.6% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.6%	22.4% 3.8 pts better	19.8% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 29.1% · Q3 12.7% · Q4 3.3% · 4Q avg 18.6%
Percentage of long-stay residents with pressure ulcers	4.0%	3.7% 0.3 pts worse	5.1% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 3.5% · Q3 1.7% · Q4 2.9% · 4Q avg 4.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	74.2%	76.4% 2.2 pts worse	81.7% 7.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q3 76.2% · 4Q avg 74.2%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-25 · Fire 2025-04-25

21 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-09-28 · Fire 2023-09-28

22 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 3 Health 2020-02-27 · Fire 2020-02-27

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-25

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2025-05-15

F · Potential for more than minimal harm 2025-04-25

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-06-02

F · Potential for more than minimal harm 2025-04-25

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-05-03

F · Potential for more than minimal harm 2025-04-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-16

F · Potential for more than minimal harm 2025-04-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-16

F · Potential for more than minimal harm 2025-04-25

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-05-15

F · Potential for more than minimal harm 2025-04-25

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2025-05-03

F · Potential for more than minimal harm 2025-04-25

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-28

F · Potential for more than minimal harm 2025-04-25

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-05-12

F · Potential for more than minimal harm 2025-04-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-06

F · Potential for more than minimal harm 2023-09-28

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-12-15

F · Potential for more than minimal harm 2023-09-28

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-10-21

F · Potential for more than minimal harm 2023-09-28

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2023-11-06

F · Potential for more than minimal harm 2023-09-28

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-10-31

F · Potential for more than minimal harm 2023-09-28

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2023-11-06

F · Potential for more than minimal harm 2023-09-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-15

F · Potential for more than minimal harm 2023-09-28

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-11-06

F · Potential for more than minimal harm 2023-09-28

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-01-31

F · Potential for more than minimal harm 2023-09-28

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2024-01-31

F · Potential for more than minimal harm 2023-09-28

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2023-11-13

F · Potential for more than minimal harm 2023-09-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-09-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-09-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-01-31

D · Potential for more than minimal harm 2023-09-28

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-11-06

D · Potential for more than minimal harm 2020-02-27

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2020-09-09

D · Potential for more than minimal harm 2020-02-27

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2020-08-31

D · Potential for more than minimal harm 2020-02-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-08-25

Inspection history

Recent health citations

J · Immediate jeopardy 2025-04-25

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-30

F · Potential for more than minimal harm 2025-04-25

F848 · Administration Deficiencies

Health

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Corrected 2025-05-12

F · Potential for more than minimal harm 2025-04-25

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-05-15

E · Potential for more than minimal harm 2025-04-25

F567 · Resident Rights Deficiencies

Health

Honor the resident's right to manage his or her financial affairs.

Corrected 2025-05-09

E · Potential for more than minimal harm 2025-04-25

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-05-15

E · Potential for more than minimal harm 2025-04-25

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-25

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2025-05-15