Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Walsh Healthcare Center during CMS and state inspections, most recent first.
Failure to submit PBJ staffing data. The facility did not electronically submit complete and accurate direct care staffing information to CMS for a quarter. The PBJ policy required timely submission of staffing data, including agency and contract staff, based on payroll and other verifiable data. The HRD said the facility had previously used a third party to submit the PBJ and that she was having issues submitting the report, and she was unable to submit the report for all three quarters prior to the deadline.
Failure to Maintain Ventilation in Shower Room and Resident Bathrooms: The facility failed to ensure adequate outside ventilation in the shower room and resident bathrooms. Surveyors observed that the shower room vents had no air flow, and the resident bathrooms attached to multiple rooms also had no air flow from the ventilation fans. The MTD stated the facility used a mechanical ventilation system and confirmed there was not any air flow after inspecting the areas.
The facility failed to consistently document, resolve, and report back on grievances raised during resident council. Residents said concerns such as missing clothing, room temperature, weekend water service, toilet tissue, food quality, and staffing were not followed up through formal grievance forms or brought back with resolutions at later meetings. A visitor also reported that grievance resolutions were not reviewed during council, and the AD stated she did not realize every concern raised in council needed to be handled as a grievance.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 48% medication error rate after observing an LPN administer multiple meds to a resident five hours late and give iron without a physician order. The MAR showed the meds were scheduled for 9:00 a.m., and the record lacked documentation that the physician was notified about the late administration or the unprescribed iron.
A resident with Alzheimer’s disease, severe cognitive impairment, and dysphagia was ordered a mechanical soft diet with nectar-thick liquids, but was repeatedly served foods that were not prepared to the required texture. Observations showed whole or only partially cut meats, whole broccoli florets, and fried chicken with bones, while the resident continued placing new bites in her mouth before finishing the previous bite and ate without staff supervision. Records and staff interviews showed the resident had a history of coughing and choking during meals, and staff did not consistently check or understand the ordered diet texture.
The facility failed to implement an antibiotic stewardship program with criteria for antibiotic use and monitoring of antibiotic therapy. One resident received multiple antibiotics for a finger infection without documentation of a culture before the first three antibiotics, and another resident remained on long-term prophylactic cefadroxil for UTI without documented monitoring for adverse reactions, effectiveness, or justification for continued use. Staff interviews showed the MD, NP, and IP were not consistently using infection criteria, and the care plan did not address the long-term antibiotic.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the quarter of 4/1/25 through 6/30/25. The facility’s Payroll Based Journal policy, implemented 1/1/25, stated that the facility was to electronically submit timely direct care staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data. Record review of the CMS submission report dated 10/9/25 showed the required data for the quarter was not submitted. During interview, the HRD stated the facility had previously used a third party to submit the PBJ, that she was responsible for submitting the data, and that she was having issues submitting the report. She also stated she was unable to submit the report for all three quarters prior to the deadline.
Failure to Maintain Ventilation in Shower Room and Resident Bathrooms
Penalty
Summary
The facility failed to ensure adequate outside ventilation by means of windows or mechanical ventilation in the shower room and resident bathrooms. During a walk-through of the shower rooms and resident bathrooms, the surveyor observed that the resident shower room had four vents but there was no air flow coming from the ventilation fans. The resident bathroom attached to room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] also had no air flow coming from the ventilation fans. The maintenance director was interviewed while touring the shower rooms and stated the facility used a mechanical ventilation system. He explained that if the belt on the motor drive was not functioning properly, it would cause a failure in air flow through the vents. He also stated the ventilation system in the bathrooms and shower room should be checked daily by housekeeping and cleaned monthly. After inspecting the shower room and the resident bathrooms, the maintenance director confirmed there was not any air flow.
Failure to Document and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to provide responses, actions, and rationale for grievances raised during resident council meetings. A review of the resident council meeting minutes showed multiple group grievances, including requests for more toilet tissue in shared bathrooms, water not being passed on weekends, concerns about the palatability of chicken, missing clothing from laundry, rooms being too hot or too cold, and the need for more support staff on weekends to cover CNA call offs. The minutes did not document resolutions for these concerns, and the record review did not show grievance forms for several of the issues brought up in resident council. During interviews, five alert and oriented residents who regularly attended resident council said the facility did not follow up on grievances brought up in the meetings and that they did not know how to file a grievance. One resident said department heads sometimes tried to address concerns during the meeting, but the manager did not complete a grievance form. Another resident said individual grievances were sometimes followed up with the resident, but group grievances were not consistently brought back to the next resident council meeting. A frequent visitor also stated that staff did not go over grievance resolutions during resident council and that she did not know whether residents knew how to file grievances. The activities director said she handled grievances but was not aware that a grievance should be written for every concern brought up during resident council and followed through the same way as an individual grievance.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, with surveyors identifying a 48% error rate, or 12 errors out of 25 opportunities for error. Facility policy required medications to be administered by authorized staff in accordance with the six rights of medication administration, including the right resident, right drug, right dosage, right route, right time, and right documentation, and stated that medications should be administered within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. During observation, an LPN administered multiple medications to a resident at 1:45 p.m., including loratadine, Arginaid, metoprolol, Colon Health, famotidine, TheraLITH XR, duloxetine, oxybutynin, pantoprazole, baclofen, Trelegy inhaler, saline nasal mist, Pataday eye drops, and iron. The resident consumed the medications and received the inhaler, nasal spray, and eye drops. The medications were ordered for 9:00 a.m. administration, making them five hours late, and the resident did not have a physician order for iron. The record did not show documentation that the physician was notified about the late administration or the unprescribed iron. Staff interviews confirmed that the resident did not have an order for iron, that late medications should be reported to the physician before administration, and that the DON was aware the medication was given without an order.
Failure to Serve Ordered Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that one resident with documented swallowing problems received food prepared in the mechanically altered form ordered by the physician. Resident #7 had diagnoses including Alzheimer’s disease and a progressive neurological disorder, severe cognitive impairment, and required set-up assistance for meals. The resident’s records showed oropharyngeal dysphagia, coughing and choking during meals, prolonged chewing, and an order for a regular diet with mechanical soft texture and nectar-thick liquids. The care plan directed staff to serve the diet as ordered and monitor for signs of swallowing difficulty. During multiple lunch observations, the resident was served foods that were not prepared according to the ordered mechanical soft diet. The resident was observed receiving items such as chicken breast cut into one-inch pieces with whole broccoli florets, a whole parmesan breaded pork chop that was only partially cut, a whole uncut Salisbury steak, and fried chicken with bones. Meal tickets documented a ground diet, but the foods served did not match the ordered texture. The resident was repeatedly observed putting additional food into her mouth before finishing chewing and swallowing the previous bite, and she ate without staff supervision or intervention. Record review showed the resident had previously requested ground meat because of missing lower teeth and had been noted to cough during meals and have trouble swallowing. Speech therapy documented that she needed smaller food sizes than a regular diet, excessive or prolonged chewing was observed, and she coughed when food was not mechanically altered. Staff interviews showed dietary and nursing staff did not consistently understand or check the required diet texture, and the dietary supervisor and registered dietitian stated they had not done documented training with dietary staff on different diet textures.
Antibiotic Stewardship Program Not Implemented
Penalty
Summary
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 residents. The facility policy stated that the program was intended to optimize treatment of infections while reducing adverse events associated with antibiotic use, and that the MD, DON, and IP each had defined responsibilities related to antibiotic prescribing practices, monitoring, and review of antibiotic use data. The policy also stated that the facility used infection surveillance criteria such as CDC NHSN surveillance definitions, updated McGeer criteria, or another surveillance tool, and that the program included monitoring response to antibiotics and laboratory results when available. However, the policy did not address long-term prophylactic antibiotics. One resident had repeated antibiotic treatment for cellulitis of the right finger. The record showed cephalexin was ordered for redness and swelling of the finger, followed by doxycycline when the finger again became red and swollen, then Bactrim DS when the finger remained pinkish at the tip. A culture of the finger was not documented before the first three antibiotics were prescribed. After the culture was obtained, the resident was changed to amoxicillin when the culture results were reviewed. The MD stated the resident had gotten a manicure that resulted in paronychia, that the treatment should have been soaking and a topical steroid, and that the infection did not require antibiotics. The NP also stated the culture should have been ordered before antibiotic use. A second resident was receiving cefadroxil once daily as a long-term prophylactic antibiotic related to UTI, with the order originating in 2023. The record did not show documentation that the facility was monitoring the resident for adverse reactions, effectiveness of the prophylaxis, or justification for continued use. The comprehensive care plan also did not include a focus addressing the need for long-term antibiotic use. Staff interviews confirmed that the facility did not use criteria to determine whether antibiotics were needed, that the MD and NP were not familiar with the McGeer criteria, and that the facility policy did not address long-term antibiotics. The MD and NP both stated the resident should have had follow-up with urology for continued use of the antibiotic, and the IP stated the facility had not been following its criteria and that a care plan with monitoring should have been initiated.
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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 Walsh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southeast Colorado Hospital Ltc | 18.2 mi | ★★★★★ | 0 | 0 |
| Stanton County Health Care Facility Ltcu | 31.9 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.