Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Southeast Colorado Hospital Ltc during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of nocturnal wandering was not provided with an individualized care plan or person-centered interventions to address wandering or elopement risk. Despite repeated documentation of wandering behaviors, staff did not conduct an elopement risk assessment or update the care plan, and unsecured exit doors allowed the resident to leave the facility unsupervised and be found several blocks away.
The facility failed to maintain an effective infection prevention and control program. Residents were not consistently offered hand hygiene before meals, and staff did not perform hand hygiene between tasks during meal service. Housekeeping staff failed to disinfect high-touch surfaces and change gloves appropriately, increasing the risk of cross-contamination.
The facility failed to accommodate the needs of two residents by installing automatic faucets that lacked temperature adjustment knobs, making it difficult for them to achieve a comfortable water temperature for daily activities. Despite grievances and complaints, no resolution was documented, and the decision to install these faucets was made without assessing resident accessibility needs.
A resident, who was cognitively intact and dependent on staff for care, was verbally abused by a CNA with a history of care concerns. Despite previous disciplinary actions, the CNA continued inappropriate behavior, including refusing toileting assistance and using inappropriate language. The facility's investigation confirmed the abuse, leading to the CNA's termination.
A facility failed to assist two residents with activities of daily living, including nutrition and personal hygiene. One resident with severe dementia struggled to eat independently and did not receive necessary assistance or nutritional supplements. Another resident with hemiplegia was left in a wheelchair for extended periods without being repositioned or having her incontinence brief changed, resulting in her being soaked with urine. Staff interviews revealed a lack of adherence to care plans and policies.
The facility failed to properly store and label medications and biologicals, with expired medications found in carts and storage rooms, and insulin pens used beyond their recommended period. Additionally, the temperature of medication and vaccine storage refrigerators was not consistently recorded. Staff interviews revealed an understanding of proper protocols, but these were not consistently followed.
Failure to Supervise and Care Plan for Wandering Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and implement person-centered interventions to prevent accidents, specifically elopement, for a resident with moderate cognitive impairment and a history of wandering. Despite multiple nursing progress notes documenting the resident's increasing restlessness and wandering throughout the facility at night, no individualized care plan or interventions addressing wandering or elopement risk were initiated. The facility's policy required staff to identify at-risk residents, assess for risk factors, and include safety interventions in the care plan, but these steps were not followed for this resident. The resident, who had diagnoses including traumatic brain injury, diabetes, and hypertension, was noted in several progress notes over multiple days to be wandering from room to room and to common areas during the night. There was no documented history of wandering prior to admission, but staff observations indicated a pattern of nocturnal wandering. Despite this, the care plan was not updated to reflect these behaviors, and no elopement risk assessment was conducted after the resident was found outside the facility several blocks away. After the elopement incident, staff placed the resident on 15-minute safety checks, but the care plan and risk assessment were still not promptly updated. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wandering behaviors, and exit doors were described as unsecured and unmonitored, allowing the resident to leave the facility unsupervised. The failure to recognize and address the resident's wandering and elopement risk resulted in the resident being found offsite by a community member.
Inadequate Infection Control Practices in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Residents were not consistently offered hand hygiene before meals, despite the presence of a hand sanitizing wipe dispenser in the dining room. Several residents, including those who propelled themselves in wheelchairs or used walkers, were observed entering the dining room and touching various surfaces without being offered hand hygiene. Staff interviews revealed a lack of awareness and understanding of the hand hygiene protocols, with some staff members unaware of the purpose of the hand wipe station or the condition of the wipes. Staff hand hygiene practices were also inadequate during meal service and assistance. Observations showed that staff members, including CNAs, did not perform hand hygiene between tasks such as serving meals, assisting residents with eating, and touching various surfaces. Despite the availability of hand sanitizer and a handwashing sink, staff were seen handling multiple items and residents without washing their hands. Interviews with the infection preventionist confirmed that staff should perform hand hygiene after touching anything other than the meal tray and plate. Housekeeping staff also failed to adhere to infection control protocols. Observations indicated that high-touch surfaces in resident rooms were not consistently disinfected, and gloves were not changed between cleaning different areas of the room. A housekeeper was seen cleaning multiple surfaces, including the toilet, without changing gloves or performing hand hygiene. Interviews with housekeeping staff and supervisors highlighted a lack of knowledge regarding proper glove use and the cleaning of high-touch surfaces, contributing to the risk of cross-contamination.
Failure to Accommodate Resident Needs with Automatic Faucets
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring they could self-adjust the water temperature from the faucets in their rooms. Both residents, who were cognitively intact and independent in self-care tasks, expressed dissatisfaction with the automatic faucets installed in their rooms. These faucets lacked adjustment knobs, making it difficult for the residents to achieve a comfortable water temperature for activities of daily living such as hand hygiene and grooming. Resident #20, who had a history of stroke, hypertension, and anemia, reported that the automatic faucet in her room was problematic as it initially dispensed cold water that quickly became too hot, causing concern about potential burns. She had previously filed a grievance about the issue, stating that the faucet was installed without prior notice and that it made her feel like her home was being altered without her consent. Despite raising the issue at a resident council meeting and filing a grievance, no resolution was documented. Resident #13, diagnosed with facial skin cancer, anxiety, and asthma, also reported difficulties with the automatic faucet, stating that it was challenging to achieve a comfortable water temperature, which affected her ability to wash her face properly. She had informed the nursing staff about her concerns, but no corrective action was taken. The maintenance director confirmed that the facility had converted all faucets to automatic ones for infection control purposes but acknowledged that some residents had their faucets changed back to manual ones due to usability issues. The director of nursing noted that the decision to change the faucets was made by maintenance without conducting an accessibility assessment for each resident.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nurse aide (CNA). The resident, who was cognitively intact and dependent on staff for mobility and personal care, expressed concerns about the care provided by a specific staff member. The resident's representative confirmed that the resident had been treated poorly by a former staff member who no longer worked at the facility. The CNA in question had a history of resident care concerns, including neglect and inappropriate communication with residents. Despite previous disciplinary actions and counseling, the facility did not adequately address the pattern of behavior. On one occasion, the CNA was reported to have been rude to the resident and refused to provide requested toileting assistance, using inappropriate language in the process. This incident was witnessed by a student nurse aide and reported to the facility's administration. The facility's investigation revealed that the CNA had been verbally abusive to the resident on multiple occasions, causing the resident to feel fearful. Although the director of nursing (DON) initially did not take action, the assistant director of nursing (ADON) and human resources director (HRD) intervened, leading to the CNA's suspension and eventual termination. The facility substantiated the verbal abuse claim based on the resident's testimony and the observations of other staff members.
Failure to Assist Residents with ADLs and Nutrition
Penalty
Summary
The facility failed to provide necessary assistance to residents who were unable to perform activities of daily living, specifically in maintaining proper nutrition and personal hygiene. Resident #4, who was diagnosed with severe vascular dementia and other health issues, was observed struggling to eat independently during multiple meal times. Despite being dependent on staff for all ADL tasks, Resident #4 was left without adequate assistance, resulting in her consuming only a small portion of her meals. The staff did not provide adaptive eating equipment or sufficient encouragement, and the resident's prescribed nutritional supplement was not administered. Resident #21, who had hemiplegia and other medical conditions, was dependent on staff for mobility and toileting. The resident reported being left in a wheelchair for extended periods without being repositioned or having her incontinence brief changed. On one occasion, she was left in the solarium from morning until late afternoon without access to a call light or assistance, resulting in her being soaked with urine and requiring a shower. The facility's policy required regular checks and assistance for residents with incontinence, which was not adhered to in this case. Interviews with staff revealed a lack of awareness and adherence to the care plans and policies in place for these residents. The DON acknowledged the oversight in Resident #21's care and the need for staff to assist residents struggling with meals, as observed with Resident #4. The facility's failure to provide necessary care and assistance to these residents highlights deficiencies in staff training and adherence to established care protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, expired medications were found in both the medication carts and storage rooms. Specifically, a bottle of Systane Balance eye drops and several bottles of calcium supplements and antacids were found with expiration dates that had already passed. Additionally, insulin pens were found to have been opened beyond their recommended usage period of 28 days. These findings indicate a lack of adherence to proper medication management protocols. Furthermore, the facility did not consistently monitor and record the temperatures of the medication storage refrigerator and the vaccine storage refrigerator. It was noted that the temperature was not recorded on 14 out of 31 days in October 2024. Interviews with staff, including an LPN and the DON, revealed that there was an understanding of the importance of maintaining proper storage conditions and removing expired medications, yet these practices were not consistently followed. The responsibility for checking and recording temperatures was assigned to night shift nurses, and all nurses were expected to check expiration dates before using medications from storage.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walsh Healthcare Center | 18.2 mi | ★★★★★ | 7 | 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.