Walsh Healthcare Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. Inspectors cited this home for failing to submit its staffing data to CMS (F0851) — see the citation below; CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

• Potential for harm · F2025-10-16 · tag F0851 — widespread
  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review the facility failed to electronically submit complete and accurate direct care staffing information.Specifically, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) the Payroll Based Journal (PBJ) for the quarter (4/1/25 thru 6/30/25) due to staff errors. Findings include:I. Facility policy and procedureThe Payroll Based Journal policy, implemented 1/1/25, was provided by the nursing home administrator (NHA) on 10/16/25 at 10:27 a.m. It read in pertinent part, It is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.II. Record reviewThe CMS submission report, dated 10/9/25, revealed the facility failed to submit the required data for the quarter. III. Staff interviewThe human resource director (HRD) was interviewed on 10/16/25 at 1:15 p.m. The HRD said the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-10-16 · tag F0923 — widespread
  Have enough outside ventilation via a window or mechanical ventilation, or both.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation. Specifically, the facility failed to ensure the exhaust fans in the shower room and resident bathrooms. Findings include:I. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021, retrieved on 10/21/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. II. Observations…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-10-16 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances identified during resident council. Findings include:I. Facility policy and procedureThe Resident and Family Grievance policy, revised 10/1/25, was provided by the nursing home administrator (NHA) on 10/14/25. It read in pertinent part, In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:The date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-16 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%).Specifically, the facility had a medication error rate of 48%, which was 12 errors out of 25 total opportunities for error. Findings include:I. Facility policy and procedureThe Medication Administration Policy, revised 6/17/25, was provided by the nursing home administrator (NHA) on 10/15/25 at 3:24 p.m. It revealed in pertinent part, Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and the right documentation.Administer within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. Medication administration timing twice a day at 8:00 a.m. and 6:00 p.m.II.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-16 · tag F0805 — failed to prepare food in a form residents can eat — isolated
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#7) of three residents reviewed received food and fluids prepared in a form designed to meet his or her needs out of 16 sample residents. Specifically, the facility failed to ensure Residents #7 was served a mechanically altered diet per physician's orders. Findings include:I. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and progressive neurological disorder (a condition that gradually damages and destroys parts of the nervous system). The 9/29/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She required set up assistance for meals. The MDS assessment indicated the resident had signs and symptoms of a swallowing disorder to include coughing or choking during meals…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-10-16 · tag F0881 — failed to use antibiotics responsibly — isolated
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#2 and #9) of three residents out of 16 sample residents.Specifically, the facility failed to:-Ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #9; and,-Ensure a system was in place to monitor Resident #2's prophylactic antibiotic use. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B, 9/10/25, was retrieved on 10/20/25 from https://www.cdc.gov/antibiotic-use/media/pdfs/Consult-pharm-11by17poster-Urinary-Tract-P.pd.Antibiotics are frequently prescribed for prolonged duration for the prevention of infection or prophylaxis in nursing homes. While antibiotic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-01-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in the kitchen. Specifically, the facility failed to ensure: -Perishable foods were discarded after the date of expiration; and, -Perishable foods were labeled and dated. Findings include: I. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) retrieved 1/29/24 from https://cdphe.colorado.gov/environment/food-regulations it read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-24 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for four of four certified nurse aides (CNAs) reviewed. Specifically, the facility did not provide inservice education based on the outcome of the performance reviews for CNA #1, #2, #3 and #4. Findings include: I. Record review CNA #1 (hired 5/4/11) had a performance review on 5/31/23. CNA #2 (hired 2/4/16) had a performance review on 3/15/23 CNA #3 (hired 6/1/2020) had a performance review on 1/16/24. CNA #4 (hired 9/20/21) had a performance review on 10/1/23. -The CNAs did not have an inservice education plans based on the outcome of the reviews. II. Interview The director of nursing (DON) was interviewed on 1/23/24 at 3:10 p.m. She said the identified aides had completed annual training, however, she did not know the aides needed to have inservice education plans developed from the annual performance review. She said she would ensure going forward the aides…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-01-24 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure resident food was palatable in taste, temperature, texture and appearance. Findings include: I. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #8 was interviewed on 1/22/24 at 9:15 a.m. He said the food at the facility was alright but it was not very good. Resident #14 was interviewed on 1/22/24 at 9:21 a.m. She said the texture of the food was too hard for her and the food was often cold. Sometimes the food looked appealing and sometimes it did not. Resident #13 was interviewed on 1/22/24 at 9:40 a.m. He said the food was not very good but he ate it. There is no point in complaining about it. Resident #5 was interviewed on 1/23/24 at 10:02 a.m. She said the food did not taste appealing and was frequently cold. The food was either too mushy or too hard. II. Observations A…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-24 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#12, #5 and #9) of six residents reviewed for unnecessary medications out of 11 sample residents were free from unnecessary drugs. Specifically, the facility failed to: -Have an effective method to track behaviors for efficacy of psychotropic medications for Residents #12, #5 and #9; and, -Obtain consent for psychotropic medications prior to administration for Residents #5 and #9. Findings include: I. Facility policy The Use of Psychotropic Medication policy, reviewed 10/4/23, was provided by the nursing home administrator (NHA) on 1/24/24. It read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. For psychotropic drugs that are initiated after admission to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in CO