Walsh Healthcare Center

In the surveyor’s words

From the most serious findings on record at Walsh Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Oct 16, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF923Oct 16, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2024

  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 [DATE]) retrieved [DATE] 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… […]

• No harm, potential for more than minimal, patternF565Oct 16, 2025

  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. […]

• No harm, potential for more than minimal, patternF730Jan 24, 2024

  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. […]