Westwood Post Acute
3185 W Arkansas Ave, Denver, CO 80219
Westwood Post Acute is a nursing home in Denver, Colorado. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
Special Focus Facility candidate
CMS puts a small number of homes in this program. CMS inspects them more often until they meet the program's exit rules.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (303) 922-1169
- Last standard health inspection
- April 25, 2025 (1 year ago)
- Certified beds
- 85
- Residents per day, on average
- 73.9
- Ownership type
- For profit - Corporation
- Legal business name
- North Star Healthcare LLC
- Chain
- Pacs Group
- Takes part in
- Medicare and Medicaid
More health citations than the Colorado average (50 vs 25).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.2 to 2.7 hours per resident per day.
CMS update of May 27, 2026
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
CMS update of March 25, 2026
Fine
CMS changed the fine from April 25, 2025 from $36,860 to $23,959.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 30, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
Payment stopped
May 21, 2025 (1 year ago)
CMS stopped payment for new admissions from May 21, 2025, for 12 days.
21 citations
Health inspection on April 25, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
25 of 210 Colorado homes (12%) got a citation at the immediate jeopardy level in 2025.
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 30, 2025.
CMS has cited this home for F0689 2 times since 2024.
Citation F0848. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
CMS lists it as corrected on May 12, 2025.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on May 15, 2025.
CMS has cited this home for F0867 2 times since 2024.
Citation F0567. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on May 9, 2025.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on May 15, 2025.
Citation F0807. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on May 1, 2025.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 15, 2025.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 1, 2025.
Citation F0626. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
CMS lists it as corrected on May 15, 2025.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on May 15, 2025.
Citation F0659. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care by qualified persons according to each resident's written plan of care.
CMS lists it as corrected on May 15, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on May 16, 2025.
CMS has cited this home for F0677 2 times since 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on May 15, 2025.
CMS has cited this home for F0679 2 times since 2020.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on May 15, 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 15, 2025.
CMS has cited this home for F0695 2 times since 2020.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on May 15, 2025.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on May 15, 2025.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on May 15, 2025.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 15, 2025.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on May 15, 2025.
Citation F0577. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
CMS lists it as corrected on May 1, 2025.
10 citations
Fire safety inspection on April 25, 2025
CMS lists this as a standard inspection.
Citation E0001. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish an Emergency Preparedness Program (EP).
CMS lists it as corrected on May 15, 2025.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on June 2, 2025.
CMS has cited this home for K0291 2 times since 2023.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on May 3, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on May 16, 2025.
CMS has cited this home for K0345 2 times since 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 16, 2025.
CMS has cited this home for K0353 2 times since 2023.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on May 15, 2025.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on May 3, 2025.
CMS has cited this home for K0541 2 times since 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 28, 2025.
CMS has cited this home for K0712 2 times since 2020.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on May 12, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 6, 2025.
CMS has cited this home for K0918 3 times since 2020.
Fine
April 25, 2025 (1 year ago)
CMS fine of $23,959 on April 25, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of August 29, 2024
Ownership
CMS lists this home under a new chain.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of June 26, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
CMS update of May 29, 2024
Fine
CMS changed the fine from September 28, 2023 from $18,975 to $12,334.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Payment stopped
April 5, 2024 (2 years ago)
CMS stopped payment for new admissions from April 5, 2024, for 25 days.
CMS update of March 28, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
17 citations
Health inspection on March 7, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
20 of 210 Colorado homes (10%) got a citation at the immediate jeopardy level in 2024.
Citation F0760. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 30, 2024.
CMS has cited this home for F0760 2 times since 2023.
Citation F0677. Severity G: actual harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 30, 2024.
Citation F0690. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on April 30, 2024.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for F0692 2 times since 2020.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on April 5, 2024.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 30, 2024.
CMS has cited this home for F0550 2 times since 2020.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on April 30, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 30, 2024.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 30, 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 30, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 30, 2024.
CMS has cited this home for F0584 2 times since 2023.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 30, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 30, 2024.
CMS has cited this home for F0684 2 times since 2020.
Citation F0691. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS lists it as corrected on April 30, 2024.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 30, 2024.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on April 30, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 30, 2024.
CMS has cited this home for F0880 3 times since 2020.
Fine
March 7, 2024 (2 years ago)
CMS fine of $29,177 on March 7, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
5 citations
Health inspection on September 28, 2023
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
55 of 210 Colorado homes (26%) got a citation at the actual harm level in 2023.
Citation F0760. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on October 21, 2023.
Citation F0552. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on October 21, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 21, 2023.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 21, 2023.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 21, 2023.
14 citations
Fire safety inspection on September 28, 2023
CMS lists this as a standard inspection.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on October 21, 2023.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on November 6, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on October 31, 2023.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on November 6, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 15, 2023.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on November 6, 2023.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on January 31, 2024.
Citation K0541. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on January 31, 2024.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on November 13, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 21, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 15, 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on January 31, 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on November 6, 2023.
7 citations
Health inspection on February 27, 2020
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 11, 2020.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 10, 2020.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 2, 2020.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on March 18, 2020.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 27, 2020.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 27, 2020.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 27, 2020.
3 citations
Fire safety inspection on February 27, 2020
CMS lists this as a standard inspection.
Citation K0311. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on September 9, 2020.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 31, 2020.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 25, 2020.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CENTENNIAL MASTER TENANT, LLC5% or greater direct ownership interest · 100% · since 10/11/2022
- PROVIDENCE GROUP NH, LLC5% or greater indirect ownership interest · 100% · since 06/30/2023
Questions
When was Westwood Post Acute last inspected?
CMS lists April 25, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Westwood Post Acute have?
CMS lists 50 health citations since February 27, 2020. CMS also calls these deficiencies.
Has Westwood Post Acute been fined?
CMS lists 2 fines in the past three years, $53,136 in total.
What is the CMS star rating of Westwood Post Acute?
Its CMS overall star rating is 2 of 5.
Is Westwood Post Acute a Special Focus Facility?
Yes. CMS lists it as a Special Focus Facility candidate.