Westwood Post Acute

F-F567 management of funds: The facility failed to ensure resident accounts were updated with the current facility name.

Cross reference

F-F577 right to survey results: the facility failed to have state inspections readily available and up to date.

Cross reference

F-F625 notice of bed hold policy: The facility failed to provide residents or POA bed hold information at time of transfer.

Cross reference

F-F626 permitting residents to return to the facility: The facility failed to re-admit residents after

a hospital transfer.

Cross reference

F-F644 coordination of preadmission admission screening and resident review (PASRR): The facility failed to ensure PASRR recommendations were followed for specialized services.

Cross reference

F-F659 quality of care: The facility failed to ensure qualified staff provided nail care for residents with diabetes.

Cross reference

F-F677 activities of daily living (ADL) care for dependent residents: The facility failed to ensure dependent residents received assistance with ADLs.

Cross reference

F-F679 activities meet interests/needs of each resident: The facility failed to ensure residents had a personalized activity program.

Cross reference

F-F685 treatment and services to maintain hearing/vision: The facility failed to ensure residents received timely services for ancillary services.

Cross reference

F-F689 accident hazards: The facility failed to supervise a resident who was a choking risk

during meals.

Cross reference

F-F695 respiratory care: The facility failed to properly clean and store a continuous positive airway pressure (CPAP) machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 55 065274 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065274 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Post Acute 3185 W Arkansas Ave Denver, CO 80219

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 0867 Cross reference

F-F698 dialysis: The facility failed to ensure physician's orders were in place for bruit and thrill for a resident receiving dialysis. Level of Harm - Minimal harm or potential for actual harm Cross reference

F-F699 trauma informed care: The facility failed to identify triggers that could cause re-traumatization. Residents Affected - Many Cross reference

F-F756 drug regimen review: The facility failed to ensure monthly medication reviews (MMR) were completed.

Cross reference

F-F791 dental services: The facility failed to ensure residents received timely dental services.

Cross reference

F-F807 hydration: The facility failed to ensure residents were provided adequate hydration.

Cross reference

F-F809 snacks at bedtime: The facility failed to ensure residents were offered snacks at bedtime.

Cross reference

F-F848 arbitration agreements: The facility failed to provide the arbitration agreement that was presented to residents contained language that provided for the selection of a venue that was convenient to both parties.

Cross reference

F-F883: immunizations: the facility failed to notify the power of attorney (POA) of immunization administration.

Cross reference

F-F921 safe/functional/sanitary/comfortable environment: the facility failed to ensure the communal resident shower was kept clean and sanitary.

III. Staff interviews

The NHA was interviewed on 4/10/25 at 6:52 p.m. He said the QAPI committee met once monthly. He said

the QAPI committee looked at eight to ten areas on a monthly basis. The NHA said this meeting was used to discuss new identified concerns within the facility by reviewing resident council minutes, grievances, identified trends and incidents. The NHA said once an identified area was identified the committee assessed

the situation to find a root cause.

The NHA said it was his responsibility to follow up on identified areas and put a performance improvement plan (PIP) in place. The NHA said the PIP would then be discussed at the next meeting to ensure there was progress in a positive manner.

The NHA said the QAPI committee had not identified any concerns when it came to: meal assistance, hydration, choking hazards, dialysis, discharges, re-admission, personal funds and posted survey results.

The NHA said infection control was discussed at all QAPI meetings. He was not aware there was an issue with continuous positive airway pressure (CPAP) machines cleaning until it was identified during the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 55 065274 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065274 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Post Acute 3185 W Arkansas Ave Denver, CO 80219

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 0867 The NHA said the facility had issues with snacks about six months ago and changed how the snacks were being distributed due to residents hoarding snacks. He said he became aware that there were not enough Level of Harm - Minimal harm or snacks available to residents during the survey. potential for actual harm

The NHA said the facility was not aware that the pharmacy medication reviews were not occurring monthly Residents Affected - Many reports until it was brought to attention during the survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 55 065274 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065274 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Post Acute 3185 W Arkansas Ave Denver, CO 80219

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20287 potential for actual harm Based on record review and interviews, the facility failed to implement policies and procedures related to Residents Affected - Few pneumococcal immunizations for one (#30) of five residents reviewed for immunizations out of 31 sample residents.

Specifically, the facility failed to ensure consent was obtained from Resident #30's representative prior to administering the pneumococcal vaccination.

Findings include:

I. Resident #30

A. Resident status

Resident #30, age 86, was admitted on [DATE REDACTED]. According to the April 2025 computerized physician's orders (CPO), diagnoses included dementia without behavioral disturbance, anxiety and mood disturbance and hypertensive heart disease with heart failure.

The 1/7/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required partial to moderate assistance with ADLs.

The MDS assessment indicated the resident was not up to date on the pneumococcal vaccine because it was offered and declined.

B. Resident representative interview

Resident #30's representative was interviewed on 4/8/25 at 9:52 a.m. The representative said she was not notified and did not give consent for Resident #30 to receive the pneumococcal vaccination prior to the administration of the vaccine. She said she had taken Resident #30 out for a visit and Resident #30 complained of her arm hurting as she had received a vaccination. The representative said she called the facility and the nurse confirmed the resident received the Prevenar 20 vaccination.

C. Record review

Review of Resident #30's electronic medical record (EMR) revealed the resident received the Prevnar 20 immunization on 3/26/25.

The resident vaccination consent for vaccinations, dated 3/21/25, revealed the consent was signed by the infection preventionist (IP). The consent form was for the pneumococcal (Prevenar 20). The consent documented, I have authority to complete this registration process and to make my health care decisions (or

the healthcare decisions for the named patient). I have been given online links/documents to read about the disease and vaccines. I believe I understand the benefits and risks of the vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 55 065274 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065274 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Post Acute 3185 W Arkansas Ave Denver, CO 80219

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 0883 Review of Resident #30's EMR failed to show the resident's representative was notified or gave consent for

the administration of the pneumococcal vaccination. Level of Harm - Minimal harm or potential for actual harm II. Staff interviews

Residents Affected - Few The director of nursing (DON) was interviewed on 4/10/25 at 1:52 p.m. The DON said the IP was responsible to maintain the immunization records and ensure the residents received the immunizations if needed. She said she reviewed Resident #30's record and confirmed the IP incorrectly signed the consent for Resident #30's pneumococcal vaccination. She said the responsible party was to sign the consent and to give permission for the vaccination. She said she would provide education to the IP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 55 065274 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065274 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Westwood Post Acute 3185 W Arkansas Ave Denver, CO 80219

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 46849

Residents Affected - Few Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public.

Specifically, the facility failed to ensure the residents' shower room was maintained in a safe and sanitary condition.

Findings include:

I. Observations

On 4/8/25 at 2:13 p.m. the facilities shower room was observed. There was black residue on the surface of

the grout lines going around the perimeter of the inside of the shower.

II. Resident representative

Resident #30's representative was interviewed on 4/8/25 at 9:43 a.m. She said the shower room was not clean and needed to have a good cleaning. She said it had been like that for some time.

III. Staff interviews and observations

The shower room was observed with the maintenance director (MTD) and the nursing home administrator (NHA) on 4/8/25 at 2:45 p.m. The MTD said the housekeeping staff cleaned the shower daily and deep cleaned the shower once a week. The MTD said the black residue could be soap (however the liquid body soap in the shower room was orange) or it could be splattered caulking (the caulking in the shower was gray). The MTD and the NHA said they were unable to identify the black residue so they requested a comprehensive mold test

The MTD was interviewed again on 4/8/25 at 3:35 p.m. He said he had a professional commercial shower sanitizer . He said he was not able to test for mold, only sanitize the shower.

The MTD was interviewed again on 4/8/25 at 4:00 p.m The MTD said the facility was able to schedule testing with an environmental testing company for the following morning.

IV. Facility follow up

On 4/14/25 at 9:22 a.m. the NHA provided the results from the mold tape inspection via email. The report included the observations of potential water damage, potential visual growth and excessive humidity and moisture in the shower. The laboratory results revealed common allergens were present but no fungal growth.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 55 065274