Walsenburg, CO
3-star overall rating with 2-star inspections with abuse icon flag with $4,893 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
23500 Us Highway 160, Walsenburg, CO
(719) 738-4540
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
74
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-31
CMS approved date
Coverage
Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.23
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.56
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.37
CMS adjusted RN staffing hours
Adjusted total hours
5.11
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Medicare spending per beneficiary | Not Available |
1.02
|
This provider is not required to submit SNF QRP data. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
93.5%
3 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.2% · Q3 95.8% · Q4 92.6% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.4% |
94.7%
1.3 pts worse
|
95.5%
2.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.4%
1.9 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.9% · Q3 5.6% · Q4 4.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
7.4%
7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
5.0%
4.6 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
11.2%
1.9 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.6% · Q3 8.7% · Q4 7.4% · 4Q avg 9.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.0% |
20.6%
2.4 pts worse
|
16.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 23.1% · Q3 21.1% · Q4 25.7% · 4Q avg 23.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.3% |
15.2%
8.1 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 26.9% · Q3 7.1% · Q4 24.9% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.2% |
14.6%
12.6 pts worse
|
14.9%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 23.3% · Q3 22.6% · Q4 28.8% · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
22.4%
6.6 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 27.8% · Q3 30.1% · Q4 30.3% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
3.7%
1.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 7.2% · Q3 6.2% · Q4 4.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.8% |
76.4%
18.6 pts worse
|
81.7%
23.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 54.2% · 4Q avg 57.8% |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-15
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-02-21
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-06-29
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-06
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-17
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-31
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-02
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-09-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-09-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-09-06
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-09-06
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-09-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-03
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-22
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-01-22
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-22
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-22
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-11
Health
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.
Corrected 2023-08-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-18
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-18
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-28
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-08-18
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-08-18
Health
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.
Corrected 2023-08-18
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2019-09-27
Health
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.
Corrected 2019-09-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-09-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-09-27
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-09-27
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-09-27
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-27
Penalties and ownership
Fine · fine $1,748
Fine
Fine · fine $3,145
Fine
Nearby options
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