Based on record review and interviews, the facility failed to prevent a significant medication error for one (#1) of three residents out of seven sample residents.Resident #1 was admitted to the facility on [DATE] with a history of cerebral infarctions due to an embolism (stroke) and a prosthetic mechanical heart valve.On 7/8/26 the facility entered the following physician's orders from Resident #1's admission orders:Coumadin (a blood thinning medication) 3 milligram (mg) tablets, give 9 mg every day for five days. Recheck the international normalized ratio (INR - a test to measure if the blood thinner is within the therapeutic level to prevent blood clotting) on day five and obtain new physician's orders for Coumadin, scheduled to start on 7/9/26 and end on 7/13/26. …
F760 citations in Colorado
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F760 more often than its own record predicts
2.07 times the share F760 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F760 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 that residents were free from significant medication errors for one (#4) of three residents reviewed for medication errors out of 11 sample residents.Resident #4, who had a diagnosis of seizures, was admitted to the facility from home on 4/27/26 for a five-day respite stay. The resident had physician's orders for levetiracetam (a medication used to treat seizures) to be administered two times per day related to her seizures.The resident was scheduled to receive the levetiracetam medication between 3:00 p.m. and 6:00 p.m., per her home medication regimen. However, the medication orders were not obtained until 4:00 p.m. (over five hours after the resident was admitted to the facility). …
Based on observations, record review and interviews, the facility failed to ensure one (#19) of one resident reviewed for medication administration out of 26 sample residents was kept free from significant medication errors.Specifically, the facility failed to ensure Resident #19 was administered sliding scale insulin per physician orders.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised November 2025, was provided by the nursing home administrator (NHA) on 8/31/26 at 7:30 p.m. …
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 2.12% | 1.91× |
| 2024 | 2.39% | 2.05× |
| 2025 | 2.69% | 2.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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