Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically, the facility's medication error rate was 8.57%, or three errors out of 35 opportunities for error.Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, revised April, 2019 was provided by the regional director of clinical services on 6/25/26 at 4:33 p.m., The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. …
F759 citations in Colorado
Medication error rate · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F759 more often than its own record predicts
1.14 times the share F759 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F759 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.
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 1.52% | 1.25× |
| 2024 | 1.57% | 1.46× |
| 2025 | 1.23% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction