Springfield, CO

Southeast Colorado Hospital Ltc

5-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

373 E 10th Ave, Springfield, CO

(719) 523-4501

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

56

Certified beds

Average residents

38

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1991-12-01

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

Hours and turnover

RN hours / resident day

1.08

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.58

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

3.83

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.49

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.66

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

4.42

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.59

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

1.40

CMS adjusted RN staffing hours

Adjusted total hours

7.10

CMS adjusted total nurse staffing hours

Case-mix index

1.06

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 49% · national 46%

SNF QRP

Medicare quality reporting measures

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

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	1.3 1.1 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.7	1.7 2 pts worse	1.8 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	93.5% 6.5 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	97.7%	94.7% 3 pts better	95.5% 2.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7%
Percentage of long-stay residents experiencing one or more falls with major injury	1.9%	3.4% 1.5 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.7%	7.4% 6.7 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	10.1%	5.0% 5.1 pts worse	5.4% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 12.2% · Q3 9.8% · Q4 10.8% · 4Q avg 10.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	24.5%	11.2% 13.3 pts worse	19.6% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 24.4% · Q3 24.4% · Q4 27.0% · 4Q avg 24.5%
Percentage of long-stay residents who received an antipsychotic medication	26.2%	20.6% 5.6 pts worse	16.7% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 28.1% · Q3 25.0% · Q4 27.3% · 4Q avg 26.2% · 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	13.0%	15.2% 2.2 pts better	16.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.2% · Q3 13.3% · Q4 19.8% · 4Q avg 13.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.3%	14.6% 8.7 pts worse	14.9% 8.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 10.8% · Q3 28.9% · Q4 29.4% · 4Q avg 23.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.8% 0.8 pts better	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% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.4%	1.5% 2.9 pts worse	1.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.9% · Q3 4.9% · Q4 2.7% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.2%	22.4% 8.2 pts better	19.8% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 14.8% · Q3 13.8% · Q4 15.6% · 4Q avg 14.2%
Percentage of long-stay residents with pressure ulcers	1.6%	3.7% 2.1 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	76.4% 23.6 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

6 health deficiencies

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

5 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2023-06-15 · Fire 2023-06-15

6 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 3 Health 2022-04-14 · Fire 2022-04-14

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-21

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2024-12-16

F · Potential for more than minimal harm 2024-11-21

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2024-12-16

F · Potential for more than minimal harm 2024-11-21

E9 · Emergency Preparedness Deficiencies

Fire Safety

Include a process for Emergency Preparedness collaboration.

Corrected 2024-12-16

F · Potential for more than minimal harm 2024-11-21

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-12-09

F · Potential for more than minimal harm 2024-11-21

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-12-14

F · Potential for more than minimal harm 2023-06-15

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2023-07-27

F · Potential for more than minimal harm 2023-06-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-07-28

F · Potential for more than minimal harm 2023-06-15

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2023-07-27

F · Potential for more than minimal harm 2023-06-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-07-28

E · Potential for more than minimal harm 2023-06-15

K908 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Corrected 2023-12-07

D · Potential for more than minimal harm 2023-06-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-07-28

D · Potential for more than minimal harm 2023-06-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-07-27

D · Potential for more than minimal harm 2022-04-14

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2022-05-02

D · Potential for more than minimal harm 2022-04-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-05-09

D · Potential for more than minimal harm 2022-04-14

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-05-02

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-04-22

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 2025-05-08

E · Potential for more than minimal harm 2024-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-21

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-21

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 2024-12-16

F · Potential for more than minimal harm 2023-06-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-07-03

E · Potential for more than minimal harm 2023-06-15

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-07-05

E · Potential for more than minimal harm 2023-06-15

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 2023-07-06

D · Potential for more than minimal harm 2023-06-15

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-07-06

D · Potential for more than minimal harm 2023-06-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-07-06

D · Potential for more than minimal harm 2023-06-15

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-07-05

D · Potential for more than minimal harm 2022-04-14

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-05-05

D · Potential for more than minimal harm 2022-04-14

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 2022-05-05

Penalties and ownership