Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Walbridge Memorial Convalescent Wing during CMS and state inspections, most recent first.
A resident group reported that chicken was served almost every day and pork was frequently served, and one resident said there was too much chicken on the menu. Menu review showed repeated chicken and pork offerings across multiple weeks, including chicken served several days in a week and pork appearing multiple times in the same week. Resident council minutes did not document the concern, and the DM acknowledged the menu lacked enough variety.
Dishwashing machine sanitation was not consistently verified in the kitchen. Staff used a temperature disk because the machine’s digital gauges were frozen, and multiple observations showed the disk reading below the required 160 degrees F surface temperature on several runs. The DM reported the machine had ongoing problems, broken parts, and a nonworking sensor, and later stated the unit was old and the facility was working with the vendor to replace it.
A facility failed to keep washcloths and hand towels consistently stocked in residents’ rooms. Several residents reported that linens were often missing, that staff sometimes said none were available, and that they sometimes had to use paper towels or previously used linens to wash their faces. Staff confirmed the unit had frequent linen shortages, CNAs were responsible for restocking, and the DON acknowledged residents should not have to ask for these items because they should already be available in the bathroom.
A resident reported that $50 was missing from her room, but the DON did not promptly notify the NHA, complete an incident report, or start an investigation. The resident said a volunteer helped search her room and she never heard back from the facility. Staff later acknowledged the allegation should have been addressed right away, and the report to the State and ombudsman was delayed.
Medication administration and storage were not consistent with professional standards. An LPN gave a resident's ophthalmic drops too close together, with only about 1 minute between doses instead of waiting the recommended time, and another LPN pre-poured medications into labeled pill cups for residents who were off the unit and stored them in the med cart drawer until later.
Failure to provide ROM support and therapy evaluation: Two residents with limited ROM did not receive ordered or indicated services. One resident with arthritis and hand contracture risk was repeatedly observed without the prescribed left-hand brace or other protective device, despite a PT recommendation and physician order for nighttime use. Another resident with dementia had a documented decline in feeding ability, but no PT or OT evaluation was completed to determine whether adaptive utensils or a device to prevent contracture were needed.
A resident with Parkinson's disease, cognitive impairment, and a history of falls continued to have unwitnessed falls despite a fall care plan with standard precautions, walker-related interventions, and OT input. The resident frequently refused staff assistance, would not reliably use the call light, sometimes ambulated without the walker, and reported issues with wet non-slip socks and an ill-fitting incontinence brief. After repeated falls, the record did not show documentation that the fall plan and interventions were reviewed for effectiveness or changed based on the resident's ongoing falls.
A resident with dementia, depression, HF, and breast cancer had a PRN lorazepam order for terminal agitation that lacked an end date and was not reevaluated beyond the 14-day limit. The MAR showed no PRN doses were given, the pharmacist requested a related diagnosis and end date, and EMR review found no physician documentation justifying continuation. An LPN was unaware of the 14-day requirement, and the DON confirmed the order should have had an end date or supporting documentation.
Failure to Implement Enhanced Barrier Precautions: The facility did not implement EBP for residents with indwelling devices. A resident with a feeding tube and urinary catheter and another resident with a urinary catheter had no PPE, including gowns, observed in or near their rooms. CNAs and an LPN reported using hand hygiene and gloves for catheter care but not gowns, and staff said they had not been trained on EBP. The IP, DON, and NHA acknowledged the facility did not yet have an EBP program in place for residents with indwelling devices.
Repetitive Menu With Excess Chicken and Pork
Penalty
Summary
The facility failed to provide a menu that offered a variety of food options and instead served a repetitive menu with a high quantity of chicken and pork. The facility policy required a seven-day restaurant-style menu to accommodate general therapeutic diets and include a variety of selections, but the weekly menus reviewed showed chicken served multiple times each week, including five days in one week and three consecutive days in another, while pork was also listed repeatedly across the same weeks. One weekly menu did not identify what residents were served for lunch on one day, and the menus for later weeks continued to show chicken and pork appearing multiple times, including pork scheduled for two of three meals on some days. Resident interviews and resident council information reflected dissatisfaction with the menu. One resident said there was too much chicken served and believed it was likely due to cost-effective protein, while a group of alert and oriented residents said they were served chicken almost every day and were frequently served pork, and that they were tired of both proteins on the menu. Resident council minutes reviewed by the surveyors did not document these concerns, although the dietary manager told residents the menu could be changed if something was not working. During interviews, the dietary manager acknowledged that too much chicken would be a problem and said he would review the menu for more variety, and the NHA stated she saw repeating proteins such as chicken and pork on the menus.
Dishwashing Machine Failed to Consistently Sanitize Dishes
Penalty
Summary
Food was not served under sanitary conditions in the main kitchen because the facility failed to ensure dishes were properly sanitized. Surveyors observed the dishwashing machine and dish cycle and found that the machine’s digital temperature gauges were frozen, so staff were using a temperature disk to check the wash and final rinse cycles. A dietary aide ran the disk through the machine and the disk read 146 degrees F after the cycle, below the 160 degrees F surface temperature referenced in the facility policy and the Food Code. During additional observations, the dietary manager ran the temperature disk through the dishwasher four times. Three of the four readings did not exceed 160 degrees F, with disk temperatures of 146 degrees F, 158 degrees F, and 155 degrees F; one reading was 165 degrees F. The dietary manager stated the machine had ongoing problems, parts were broken, and the digital sensor gauge had not been working for a while. He also stated the vendor had provided the temperature disk because the machine’s sensor was not functioning properly. Later the same day, after the dietary manager learned how to place the temperature disk in the machine and after one sensor was reset, the disk was placed on a rack like a plate and the final rinse sensor read 184.82 degrees F while the disk read 170 degrees F. The dietary manager stated the machine was old, that he was working with the vendor to get a new one, and that new temperature gauges had been ordered because staff were relying on the disk to check sanitation levels. The nursing home administrator stated the facility was in the process of replacing the machine and that a new machine had been approved.
Inconsistent Room Stocking of Washcloths and Hand Towels
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when it did not consistently provide washcloths and hand towels in the rooms of four residents. Resident #13, who had diagnoses including atrial fibrillation, depression, anxiety, osteoporosis, heart failure, dementia without psychotic disturbance, and anemia, was observed on one occasion with no hand towels or washcloths in the bathroom and later with only one hand towel and no washcloths. Resident #13 stated she frequently did not have these items in her bathroom and felt she had to ask staff repeatedly for something simple. Resident #26, who was cognitively intact and independent with personal hygiene and dressing but needed moderate assistance with bathing, reported that washcloth stocking in her room was inconsistent and that staff sometimes told her none were available. Resident #27, also cognitively intact and independent with bathing and toileting, said washcloths and hand towels were not consistently stocked and that staff sometimes told her no more washcloths were available until the next laundry delivery. Resident #27 also stated she sometimes had to use the corner of a previously used washcloth or towel to wash her face. Resident #28, who was cognitively intact and independent with personal hygiene, dressing, and toileting and needed minimal assistance with bathing, said the facility did not always have washcloths or hand towels available and that she sometimes had to use paper towels to wash and dry her face and hands. Additional observations found no washcloths or hand towels in the rooms of two other residents. Staff interviews confirmed that each resident’s room should have these linens, that CNAs were responsible for restocking them, and that the unit had frequent shortages. The DON also acknowledged that paper towels were not adequate for a home-like environment and that residents should not have to ask for washcloths because they should already be available in the bathroom.
Delayed Investigation of Missing Resident Money
Penalty
Summary
The facility failed to timely investigate and report an allegation of misappropriation of property involving a resident who was cognitively intact, had a BIMS score of 15, used a walker for mobility, and was independent with most ADLs. The resident reported that a $50 bill had been placed under her pillow and later could not be found. She said she had reported the missing money when she realized it was gone, but she did not hear anything back from the facility after making the report. The resident stated the money had been missing for a couple of months before the matter was addressed during the survey. She said a volunteer helped her look for the money in her room, but it was not found. She also said she was unsure whether the money had been misplaced in her room or taken by someone. The resident’s account identified the missing money as a gift she intended to use to buy her grandson a present. Facility staff acknowledged that the allegation was not promptly followed up. The DON stated the resident reported missing money in October, but the DON was leaving for an appointment and then was on leave for a week. She said she informed an LPN, but did not notify the NHA, complete an incident report, or initiate an investigation at that time. The NHA later stated the allegation should have been reported and investigated right after it was brought to staff, and that the staff search of the resident’s room occurred only on the weekend following the report. The facility’s own documentation showed the money was last seen on 10/30/25, reported missing later that day, but the allegation was not reported to the NHA and risk manager until 12/10/25 and not reported to the State agency and ombudsman until 12/11/25.
Medication Administration and Storage Not Consistent With Standards
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with professional standards of practice for one resident. Resident #19, who had dementia, anxiety, macular degeneration, legal blindness, and severe cognitive impairment, was observed on 12/10/25 receiving two ophthalmic medications. LPN #3 administered Refresh Ophthalmic Solution to both eyes and then administered prednisolone acetate to the right eye only 1 minute and 8 seconds later, which was below the recommended minimum wait time of five minutes between eye medications. LPN #3 stated she knew the wait time was not appropriate and said she normally would give the resident an oral medication between the eye drops, but that was not the routine during the observation because the resident was sleepy. The facility also failed to ensure medications were not pre-poured. During observation of the medication storage area, three pill cups were found in the top drawer of the medication cart, each containing one pill and labeled only with an unidentified resident's initials and the scheduled time, but not the medication name. LPN #1 said he had prepared the medications for three residents who were not on the unit during lunch and placed the cups in the cart to give later when they returned. He said he did not check whether the residents were on the unit before preparing the medications. The DON and NHA both stated that medications should not be stored in cups in the cart and that the medications should have been prepared again when the residents returned.
Failure to Provide ROM Support and Therapy Evaluation
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to maintain or improve range of motion for two residents with limited ROM. One resident had a physician order and PT recommendation for a left-hand thermoplastic splint and a red foam device in the palm of the left hand at bedtime for prevention of contracture, but observations showed the resident repeatedly without the brace or any protective device in the hand. The resident’s hands were observed closed in a fist position, and the resident stated the hands were always that way because of arthritis and that it was painful to open them. A second resident with dementia and significant cognitive impairment was observed sitting with both hands resting closed in the lap, with the pads of the fingers resting on the palms. The resident had dried blood on the left hand and nails and required assistance to open the hands for cleaning. The record showed a decline in the resident’s ability to feed herself across quarterly MDS assessments, moving from set-up and clean-up assistance to supervision and cues, but no PT or OT evaluation was completed to determine whether adaptive feeding utensils could help or whether a device was needed to prevent contracture. Staff interviews reflected that the first resident’s brace could not be located during care, and staff stated a washcloth could have been placed in the hand if the brace was unavailable. For the second resident, CNAs reported the resident had been needing more help with eating over the past few months and that they had heard of an adaptive utensil being used previously, but they had not seen one on the meal tray or in use. The DON stated she was not aware of the documented decline in feeding ability and said the facility had not recently completed a PT or OT assessment for the resident.
Failure to Update Fall Interventions for a High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that one resident was free from accident hazards and received adequate supervision to prevent accidents. Resident #4 was identified as high risk for falls due to Parkinson's disease, loss of balance, impaired decision making, and impulsive behavior. The resident also had depression, type 2 diabetes with polyneuropathy, and a left rotator cuff tear. The resident's MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15 and need for supervision or cues with ambulation using a walker over 50 feet. The resident's care plan included interventions such as anticipating needs, keeping the call light within reach, encouraging call light use, using non-slip floor grips at the bedside, ensuring proper footwear, and reviewing prior falls to determine causes and alter or remove contributing factors. OT evaluation documented impaired cognition, limited safety awareness, and inability to demonstrate safe brake use with the four-wheeled walker. OT discharge documentation recommended staff assistance with all out-of-bed transfers because of high fall risk and poor walker management, and staff rounding as able because of lack of call light use and poor recall. Despite these identified risks and interventions, the resident experienced multiple unwitnessed falls. One fall occurred when the resident got up from bed using the walker to retrieve an item from the floor, leaned forward, lost balance, and struck the face on the floor, causing a large forehead hematoma, facial bruising, nose bleeding, and right knee bruising. Another fall occurred when the resident walked back from the bathroom without the walker or staff assistance, tried to sit on the walker, and it rolled away. A later fall occurred after the resident refused to use the call light or ask for help, removed non-slip socks because they were wet from an incontinence episode, and fell overnight. The record did not show documentation that the facility reviewed the fall care plan and interventions after the falls to determine whether they were effective or whether new interventions were needed, and staff interviews confirmed the resident frequently ambulated without assistance, often refused a gait belt, and continued to fall while going to or from the bathroom.
PRN Lorazepam Order Lacked Required End Date or Reevaluation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident by not discontinuing or reevaluating a PRN lorazepam order after 14 days. The resident was greater than 65 years old, admitted with diagnoses including dementia without behavioral disturbance, depression, heart failure, and malignant neoplasm of the left breast. The 10/8/25 MDS showed significant cognitive impairment with short-term and long-term memory deficits, and no behavioral symptoms of yelling, kicking, hitting, or refusal of care during the review period. The resident required substantial assistance with eating and oral hygiene and was dependent on staff for repositioning, toileting, bathing, and dressing. Review of the December 2025 CPO showed an order for lorazepam 2 mg/ml oral liquid, 0.25 ml by mouth every six hours as needed for terminal agitation, ordered 11/20/25 with no end date. The November 2025 and December 2025 MARs showed no PRN doses were administered during that timeframe. The pharmacist’s monthly medication review dated 11/28/25 documented requests for a related diagnosis and end date for the PRN lorazepam order, but the medication had not been discontinued or reevaluated at the time of the survey. EMR review found no physician documentation justifying continuation of the PRN lorazepam beyond 14 days. An LPN confirmed the order had no end date and was unaware of the 14-day requirement, while the DON stated she knew PRN anxiolytics required a 14-day end date or physician documentation to continue beyond 14 days.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment because it did not implement enhanced barrier precautions for residents with indwelling medical devices. Resident #2 had a feeding tube and an indwelling urinary catheter, and Resident #8 had an indwelling urinary catheter. During observations, no PPE, including gowns, was seen in or near either resident’s room. Staff interviews showed that CNAs and an LPN were performing catheter-related care with hand hygiene and gloves, but not gowns, and they were not following enhanced barrier precautions. CNA #5 and CNA #4 said they had not heard of or received training on EBP. LPN #2 said she wore sterile gloves when cleaning a catheter but did not wear a gown, and she believed EBP applied only to residents with compromised skin integrity. The IP said he was new to EBP and was not aware that residents with indwelling devices such as catheters and feeding tubes required EBP with direct care. The DON said the facility did not have an EBP program in place yet, and the NHA and risk manager said they had only reviewed EBP for residents with wounds during QAPI meetings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Meeker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand River Health Care Center | 36.5 mi | ★★★★★ | 9 | 1 |
| Colorado State Veterans Nursing Home - Rifle | 36.7 mi | ★★★★★ | 2 | 0 |
| Yampa Valley Healthcare Center | 38.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.