Southeast Colorado Hospital LTC

In the surveyor’s words

From the most serious findings on record at Southeast Colorado Hospital LTC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 15, 2023

  Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. […]

• No harm, potential for more than minimal, patternF880Nov 21, 2024

  Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating; -Ensure hand hygiene was performed appropriately while serving meals and assisting residents with eating; -Ensure housekeeping staff disinfected high touch surfaces (call lights, bed controls, hand rails and light switches) in resident rooms; -Ensure gloves were changed and hand hygiene was performed appropriately when needed during the cleaning of residents' rooms. Findings include: I. […]

• No harm, potential for more than minimal, patternF584Jun 15, 2023

  Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in eight of 35 resident rooms in two hallways. Specifically, the facility failed to ensure walls and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 6/14/23 at 2:00 p.m. revealed: room [ROOM NUMBER]: The wall behind the resident's headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. room [ROOM NUMBER]: The wall behind the resident's headboard had deep scratches and gouges approximately 11 inches long by one inch wide from the bed being lifted and lowered. […]

• No harm, potential for more than minimal, patternF758Jun 15, 2023

  Based on observations, record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for two (#32 and #29) of five residents out of 21 sample residents. Specifically, the facility failed to: -Evaluate the use of an as needed PRN antipsychotic medication by a physician within 14 days for Resident #38; -Provide non-pharmacological interventions for Resident #38 prior to administration of a PRN antipsychotic medication; -Identify and track behaviors for the use of psychotropic medications for Resident #38 and #29; -Monitor side effects of psychotropic medications for Resident #38 and #29; -Evaluate the use of an as needed PRN psychotropic medication by a physician within 14 days for Resident #29; and, -Provide… […]

• No harm, potential for more than minimal, isolatedF689Apr 22, 2025

  Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Specifically, the facility failed to: -Ensure Resident #1 had an individualized care plan with person-centered interventions to prevent elopement; and, -Ensure Resident #1 was provided with the supervision necessary to prevent an elopement. Findings include: I. Facility policy and procedure The Elopement and Wandering policy and procedure, revised June 2019, was provided by the nursing home administrator (NHA) on 4/22/25 at 3:05 p.m. […]