JCIPatientSafety.orgHospital Quality Directory

Critical Access Hospitals · Government - Hospital District or Authority

Spanish Peaks Regional Health Center

Not rated overall

CMS reports safety and quality measures for this hospital but does not assign an overall star rating. See scores below.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device DaysNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed CasesNot available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter DaysNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted CasesNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed CasesNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures6Not available
SSI - Colon Surgery: Predicted Cases0.141Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of ProceduresNot available
SSI - Abdominal Hysterectomy: Predicted CasesNot available
SSI - Abdominal Hysterectomy: Observed CasesNot available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days4654Not available
MRSA Bacteremia: Predicted Cases0.097Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence LimitSame as national
Clostridium Difficile (C.Diff): Upper Confidence Limit2.914Same as national
Clostridium Difficile (C.Diff): Patient Days4654Same as national
Clostridium Difficile (C.Diff): Predicted Cases1.028Same as national
Clostridium Difficile (C.Diff): Observed Cases0Same as national
Clostridium Difficile (C.Diff)0.000Same as national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.9Same as national32
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patientsNot available
Death rate for pneumonia patientsNot available
Death rate for stroke patientsNot available
Pressure ulcer rateNot available
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rateNot available
In-hospital fall-associated fracture rateNot available
Postoperative hemorrhage or hematoma rateNot available
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rateNot available
Postoperative sepsis rateNot available
Postoperative wound dehiscence rateNot available
Abdominopelvic accidental puncture or laceration rateNot available
CMS Medicare PSI 90: Patient safety and adverse events compositeNot available

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patientsNot available
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15Same as national40
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.7Same as national89
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission RateNot available

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating49
Doctor communication - star rating49
Communication about medicines - star rating49
Discharge information - star rating49
Cleanliness - star rating49
Quietness - star rating49
Overall hospital rating - star rating49
Recommend hospital - star rating49
Summary star rating49

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumelow
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination98268
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better112380
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better111367
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better15213
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen14439
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing2977
Appropriate care for severe sepsis and septic shock
Septic Shock 3-Hour Bundle
Septic Shock 6-Hour Bundle
Severe Sepsis 3-Hour Bundle
Severe Sepsis 6-Hour Bundle
Discharged on Antithrombotic Therapy
Anticoagulation Therapy for Atrial Fibrillation/Flutter0
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural Measure

Frequently asked questions

How is Spanish Peaks Regional Health Center rated?
CMS does not assign an overall star rating to Spanish Peaks Regional Health Center, but does publish underlying safety and quality measures shown on this page.
Does Spanish Peaks Regional Health Center have emergency services?
Yes. Spanish Peaks Regional Health Center operates a 24/7 emergency department.
Where is Spanish Peaks Regional Health Center located?
Spanish Peaks Regional Health Center is located at 23500 Us Highway 160, Walsenburg, CO 81089.
What type of hospital is Spanish Peaks Regional Health Center?
Spanish Peaks Regional Health Center is classified by CMS as a Critical Access Hospitals facility (Government - Hospital District or Authority).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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