Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SOUTHEAST COLORADO HOSPITAL LTC
SPRINGFIELD, CO · 56 certified beds · Last Life Safety survey November 21, 2024
CMS Certification Number 06A185 · first certified December 1991
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
15 citations — more than 43% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: May 2026 to November 2026. This facility’s last Life Safety survey was November 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
3 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 14, 2022 | 3 |
| June 15, 2023 | 7 |
| November 21, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 2 | 2024-11-21 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-11-21 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2024-11-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-04-14 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2024-11-21 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-06-15 |
| K-0912 | Have power receptacles that are properly grounded. | 1 | 2023-06-15 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-04-14 |
What the citations cover
- Egress Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Services Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
| Smoke Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 21, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 16, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (December 16, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 14, 2024) |
June 15, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0908 | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Waiver has been granted (December 7, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (July 27, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 28, 2023) |
April 14, 2022 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (May 2, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 9, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 2, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.