Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#1) out of three residents reviewed out of three sample residents. s out of three sample residents.Resident #1 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (lungs struggle to get enough oxygen into the blood), interstitial pulmonary disease (a condition that causes inflammation and scarring in the lungs), pulmonary hypertension (high blood pressure in the arteries connecting the heart to the lungs), chronic obstructive pulmonary disease with acute exacerbation (sudden worsening of respiratory symptoms like shortness of breath and coughing), and pneumonia (a lung infection).The hospital referral… …
F578 citations in Colorado
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F578 less often than its own record predicts
0.24 times the national share — cited less often here than elsewhere.
Of every deficiency written in Colorado in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F578 findings written in Colorado, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#1) of three residents reviewed for advanced directives out of 10 sample residents. Upon Resident #1's admission to the facility on [DATE], a licensed practical nurse (LPN) #3 interviewed Resident #1 and filled out the advanced directive paper form with the necessary information indicating the resident chose to be a DNR (do not resuscitate) status. LPN #1 did not record the resident's DNR status in Resident #1's electronic medical records (EMR) as he was required to do. On [DATE] the medical provider discussed the decision to be a DNR status with Resident #1 and her family. …
Based on record review and interviews, the facility failed to maintain accurate medical records for advance directives on each resident for two (#40 and #101) of eight residents reviewed out of 42 sample residents. Specially, the facility failed to ensure Resident #40 and Resident #101's medical orders for scope of treatment (MOST) form corresponded with the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR).Findings include:I. Resident #40 A. Resident statusResident #40, age less than 65, was admitted [DATE]. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.42% | 0.40× |
| 2024 | 0.37% | 0.38× |
| 2025 | 0.22% | 0.24× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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