Julesburg, CO

Sedgwick County Memorial Nursing Home

1-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

901 Cedar St, Julesburg, CO

(970) 463-6229

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

32

Certified beds

Average residents

14

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1991-06-01

CMS approved date

Coverage

Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing

LPN hours / resident day

1.68

Licensed practical nurse staffing

Aide hours / resident day

4.61

Nurse aide staffing

Weekend hours

6.08

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.8	1.3 1.5 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	6.1	1.7 4.4 pts worse	1.8 4.3 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.0%	93.5% 3.5 pts better	93.4% 3.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents experiencing one or more falls with major injury	6.1%	3.4% 2.7 pts worse	3.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	0.0%	7.4% 7.4 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	9.2%	5.0% 4.2 pts worse	5.4% 3.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.8%	11.2% 2.6 pts worse	19.6% 5.8 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	16.1%	20.6% 4.5 pts better	16.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3
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
Percentage of long-stay residents whose ability to walk independently worsened	23.6%	15.2% 8.4 pts worse	16.3% 7.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	28.8%	14.6% 14.2 pts worse	14.9% 13.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	6.4%	0.8% 5.6 pts worse	1.0% 5.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	1.5%	1.5% About the same	1.7% 0.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.7%	22.4% 1.7 pts better	19.8% 0.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	4.0%	3.7% 0.3 pts worse	5.1% 1.1 pts better	Long Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-10 · Fire 2025-09-10

6 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 2 Health 2023-12-13 · Fire 2023-12-13

2 health deficiencies

Top issue: Environmental (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-08-31 · Fire 2022-08-31

7 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-10

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-10-04

Inspection history

Recent health citations

G · Actual harm 2025-09-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-11-06

F · Potential for more than minimal harm 2025-09-10

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2025-11-06

D · Potential for more than minimal harm 2025-09-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-10-04

D · Potential for more than minimal harm 2025-09-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-10-04

D · Potential for more than minimal harm 2025-09-10

F761 · Pharmacy Service Deficiencies

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 2025-10-04

D · Potential for more than minimal harm 2025-09-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-04

F · Potential for more than minimal harm 2023-12-13

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2024-03-12

E · Potential for more than minimal harm 2023-12-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-12

G · Actual harm 2022-08-31

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-09-30

G · Actual harm 2022-08-31

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2022-09-30

F · Potential for more than minimal harm 2022-08-31

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-09-30

F · Potential for more than minimal harm 2022-08-31

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2022-09-30

E · Potential for more than minimal harm 2022-08-31

F758 · Pharmacy Service Deficiencies

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 2022-09-30

E · Potential for more than minimal harm 2022-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-09-30

E · Potential for more than minimal harm 2022-08-31

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2022-09-30

Penalties and ownership

What sits behind the stars

$0 2025-09-10

Payment Denial

Payment Denial · denial start 2025-10-09 · 28 days

28 day denial

Ownership

Nearby options

Other facilities in reach

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Regent Park Nursing And Rehabilitation

Holyoke, CO

5-star overall rating with 5-star inspections with $8,469 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

Overall: 5 / 5
Health: 5 / 5
Staffing: 2 / 5
Fines: $8,469

#2