Westwood Post Acute

Quality of Life and Care Deficiencies

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

Administration Deficiencies

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

Administration Deficiencies

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

Emergency Preparedness Deficiencies

Establish an Emergency Preparedness Program (EP).

Egress Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

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

Resident Rights Deficiencies

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

Pharmacy Service Deficiencies

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

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Infection Control Deficiencies

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

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Administration Deficiencies

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

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Services Deficiencies

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

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Egress Deficiencies

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.

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

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

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Provide properly protected cooking facilities.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

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

A licensure survey was completed on 4/7/25 to 4/25/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#45) of three residents reviewed out of 29 sample residents. Resident #45 was admitted on 3/17/25 for long-term care with a diagnosis of bipolar (mental illness), borderline personality disorder, intellectual disability and dysphagia/oropharyngeal phase (difficulty in swallowing due to issues in the part of the throat located behind the mouth). On 3/18/25 Resident #45 had an episode of choking after she grabbed a handful of leftover refried beans and shoved them into her mouth before the staff could stop her and she aspirated. The resident required the Heimlich maneuver (abdominal thrusts used to remove food or particles stuck in the airway) and suctioning. The 4/5/25 physician' s order revealed, based on assessments from the speech therapist (ST), Resident #45 required one-on-one supervision during meals, cueing for small bites/sips, slow rate, redirection to prevent wandering and an upright positioning with all oral intake. Observations during the survey revealed the one-on-one staff member did not offer Resident #45 cueing for small bites/sips, slow rate or an upright position with oral intake. Additionally, the one-on-one staff member left the resident alone during the meal. The facility' s failure to ensure identified interventions for Resident #45' s known choking risk were implemented consistently created the potential for serious harm for Resident #45. Findings include:I. Choking supervision facility failuresThe facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for Resident #45 after the resident had a choking incident on 3/18/25.The facility' s failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for Resident #45. On 4/25/25 at 8:15 a.m., the nursing home administrator (NHA) was notified of the situation of potential serious harm c..

A recertification survey with complaint #CO36903, #CO38113, #CO38591, #CO39557 and Incident #39640 was complet.. An Emergency Preparedness survey was conducted from 4/7/25 to 4/25/25. One deficiency was cited. Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable envir.. Based on observations, record review and interview, the facility failed to ensure residents, family members and legal.. Based on observations, record review and interviews the facility failed to ensure drinks, including water and other liq.. Based on observations, record review and interviews the facility failed to provide snacks in one of one nourishment r.. Based on observations, record review and interviews, the facility failed to ensure one (#9) of three residents who req.. Based on observations, record review and interviews, the facility failed to ensure one (#112) of one resident reviewe.. Based on observations, record review and interviews, the facility failed to ensure residents received adequate superv.. Based on observations, record review and interviews, the facility failed to ensure that services provided or arranged .. Based on observations, record review and interviews, the facility failed to provide one (#30) out of five residents out.. Based on observations, record review and interviews, the facility failed to provide one resident (#30) with profession.. Based on record review and interview, the facility failed to ensure the drug regimen of each resident was reviewed a.. Based on record review and interviews, the facility failed permit a resident to return after a hospitalization or thera.. Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identif.. Based on record review and interviews, the facility failed to ensure proper treatment and assistive devices to mainta.. Based on record review and interviews, the facility failed to ensure that personal funds accounts were managed adeq.. Based on record review and interviews, the facility failed to ensure the facility' s binding arbitration agreement conta.. Based on record review and interviews, the facility failed to establish and maintain a comprehensive emergency prep.. Based on record review and interviews, the facility failed to implement policies and procedures related to pneumoco.. Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission scr.. Based on record review and interviews, the facility failed to provide notice of bed hold policy and return for two (#3.. III. Resident #42A. Resident statusResident #42, age 73, was admitted on 12/15/22. According to the April 2025 CPO,.. IV. Resident #20A. Resident statusResident #20, age less than 65, was admitted on 4/2/22. According to the March 20..

STANDARD not met; Based on record review during the survey, it was determined that the facility failed to maintain sprinkler-protected areas per Life Safety 101, 19.3.2.5 and NFPA 80, 5.2.The roll-down fire doors used as an option for protection against a hazardous area requiring a one-hour separation between the main corridor and kitche.. STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with Life Safety Section 19.3.2.1, and 9.5. The laundry chute door is missing the self-closing device not meeting the fire rated assem.. STANDARD is not met as evidenced by: Based on record review during the survey; it was determined that the facility failed to conduct fire drills per the Life Safety Code, Section 19.7.1.2 and 4.7. Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the second shift in the second quart.. STANDARD is not met as evidenced by: Through record review and staff interview during the survey, the facility failed to maintain the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to .. STANDARD is not met as evidenced by: Based on observation and staff interviews during the survey, it was determined that the fire resistance rating of smoke barrier walls was not maintained in accordance with the Life Safety Code Section 19.3.2.1Wall penetrations found above the fire doors in the following locations; Santa Fe Lobby, Southeast, N.. STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8.The fa.. STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. Three support hangers have been disconnected from the sprinkler piping in the boiler-room.NFPA 101 2012 Edi.. STANDARD not met based on observation and staff interviews during the survey. It was determined that the facility failed to maintain emergency power systems under Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 5.2.3. The remote annunciator is non-functional and ins.. STANDARD was not met based on observation and staff interviews regarding the emergency lighting. The facility failed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. An itemized list of each emergency lighting fixture was not available during the record review of the facility-required testing of the battery-powered emergency .. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K0000), are informational only and a representation of the facility' s general characteristics. The facility is a one story of Type II (111) construction. A partial basement is us..