Citations in Colorado
Statistics, citations and compliance trends for long-term care facilities in Colorado.
Statistics for Colorado (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Colorado
Kitchen food storage and sanitation deficiencies were identified when unlabeled and undated fruit cups and pies were found in the refrigerator, the ice scoop holder and microwave had visible residue and food buildup, and raw beef was stored above a prepared salad mixture on a utility cart. Staff and the DM acknowledged that prepared foods should be labeled and dated, equipment should be kept clean, and raw meat should be separated from ready-to-eat foods to prevent cross-contamination.
Surveyors found that resident rooms and shower areas were not maintained in a clean, comfortable, and homelike condition. Observations showed dust, cobwebs, debris, peeling wallpaper, damaged doors, and dirty or broken wall AC units in resident rooms, while shower rooms had leaking ceilings, wet and warped flooring, missing and cracked tile, damaged walls, and shower heads wrapped with coban. Residents and staff confirmed several of the issues, including a broken door, dust blowing from an AC unit, and a shower head that was broken and difficult to use.
The facility failed to complete and document discharge planning for two residents. One resident's record did not clearly document the discharge reason, the discharge location was inconsistent across records, and the EMR did not show the reconciled med list and care plan as part of the discharge documentation. For the other resident, the care plan was not updated to reflect a preference to transfer to another SNF, and the EMR lacked documentation of discharge preparation in a form the resident could understand.
Pest Control Program Failed to Control Mice and Insects The facility did not maintain an effective pest control program to keep the LTC building free of mice, spiders, and other insects. Surveyors observed an open kitchen alleyway door, a gap under an exterior exit door, spiders in hallways, and traps in resident rooms containing spiders, bugs, and mouse droppings. Residents reported spiders on beds and walls, mice in rooms and hallways, and mouse droppings in rooms, while resident council minutes showed the mouse problem had continued for months. Pest control invoices repeatedly noted open doors and door gaps, but those issues remained unresolved in the observations reviewed.
Improper medication labeling, expired drugs, and unsecured storage were found in the facility. Surveyors observed expired diphenhydramine and milk of magnesia, eye drops and insulin pens without open dates, and multiple bottles of latanoprost and Refresh Tears without required labeling on a medication cart. Surveyors also found a medication closet and a storage room left unlocked, with heparin syringes, IV fluids, and other supplies stored in areas accessible from resident hallways.
Failure to Monitor Long-Term Antibiotic Use: A resident with CKD and recurrent UTIs was receiving daily cephalexin for UTI prophylaxis, but the facility did not document a clear rationale or effectively monitor the ongoing antibiotic use. Staff interviews confirmed the IP could not find supporting documentation, an RN did not know why the resident was on antibiotics, and the NP noted the resident had been educated about MDRO risk but refused to stop the medication; no urology documentation was found.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food items in the main kitchen refrigerator were left unlabeled and undated. During the kitchen tour, seven fruit cups and three strawberry cream pies were observed without labels identifying the food item, preparation date, or discard date, and on a later tour three fruit cups were still present without those labels. The dietary manager stated the fruit cups had been prepared the previous day and should have been labeled by the staff member who prepared them, and staff identified that prepared foods were supposed to be labeled and dated before being placed in the refrigerator. The ice scoop holder and the microwave were not maintained in a sanitary condition. The ice scoop holder contained an accumulation of white residue on the interior bottom surface during the initial kitchen tour, and the same residue was still present on a follow-up tour. The microwave interior contained dried food splatter and yellow grease accumulation. Staff interviews indicated that the microwave and ice scoop holder were expected to be cleaned by dietary aides or any staff member who used them, and the dietary manager stated the microwave should be cleaned frequently and the ice scoop holder should be cleaned when residue is observed. Raw beef was stored on the top shelf of a utility cart in the cook line area with a covered pan of prepared salad mixture directly beneath it on the lower shelf. Staff stated that raw meat and ready-to-eat foods should be stored separately to prevent cross-contamination, and the dietary manager confirmed that ready-to-eat food should not be stored beneath raw meat. The dietary manager also stated the salad mixture had been from the previous day and had been used for chicken wraps, and that she had noticed it in the refrigerator that morning and intended to discard it because it could not be used again.
Unsafe and Unclean Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to provide a comfortable and homelike environment in resident rooms and shower areas. The facility policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, and that resident rooms are to be cleaned regularly and as needed, with blinds, curtains, and windows checked and cleaned if necessary. Despite this, surveyors observed multiple resident rooms with dust, cobwebs, debris, peeling wallpaper, damaged walls, and broken room features. In one resident room, the blinds were coated with visible dust and cobwebs, and dead bugs were found in the window sill. In another room, the window sill had a layer of dust and the wall air conditioner contained dust and small pieces of debris. Another room had multiple brown spots on the wall behind the bed, and a bathroom wall had missing and peeling wallpaper around the perimeter. Additional observations included a hole in a bathroom door, a missing door bolt, latch, and face plate with broken wood around the handle, cobwebs in a windowsill, black pinpoint spots and peeling wallpaper on window jambs, and dust and debris inside a wall air conditioner. Resident interviews confirmed concerns with these conditions, including a resident who said the blinds did not block the sun, another who said dust from the wall air conditioner blew onto her wheelchair, and another who reported a broken door that had gotten stuck closed. The facility also failed to keep shower rooms and spas in good working condition. In one shower room, the ceiling tile was stained and drooping, the wall paint was bubbling and damp, the floor was warped and soft, tile was missing from the baseboard area, the wall was damaged with gouges and missing sections, and the shower stall floor was wet from a leak in the ceiling with cracked tile inside the stall. In another shower room, shower heads and holders in two stalls were wrapped with coban, and in a third shower room there was a visible gap in the caulking where floor tile met wall tile. A resident with a nephrostomy site reported that the shower head in the shower room was broken and wrapped with coban, and that she had to hold the shower head up while showering. Staff and maintenance interviews confirmed awareness of several of these conditions, including damaged walls, missing tiles, a ceiling leak, and shower heads and holders that were on back order.
Discharge planning and transfer documentation were incomplete for two residents
Penalty
Summary
The facility failed to revise and implement effective discharge planning for two residents, including documentation of the discharge process, the reason for discharge, and the required discharge paperwork provided at transfer or discharge. For one resident, the record did not consistently reflect the discharge location, and the discharge summary documented a home/community discharge with the reason listed only as "other," without additional explanation. The record also did not include documentation of the reconciled medication list and care plan in the discharge summary, and the resident's receipt signature was present without a date. Staff interviews indicated the resident had been told she had community Medicaid and that her niece would take her home, but the EMR still contained notes indicating the resident was in the hospital after discharge. The first resident had diagnoses including acute respiratory failure, myocardial infarction, end stage renal disease, congestive heart failure, vascular dementia, and metabolic encephalopathy. The MDS documented the resident as cognitively intact for decision-making, needing partial to moderate assistance with ADLs, and having an unplanned discharge to a short-term general hospital, although other documentation and staff statements indicated discharge home. The discharge care plan had been developed for long-term care and included interventions related to IDT discharge planning, but the discharge summary did not document the reason for discharge in a clear manner or show the required discharge documents as part of the record. For the second resident, the facility did not update the discharge care plan to reflect the resident's preference to transfer to another facility, and the EMR lacked documentation of preparation provided before transfer in a form and manner the resident could understand. This resident had diagnoses including chronic respiratory failure with hypoxia, malignant neoplasm of connective and soft tissue of the right lower limb, and hypothyroidism, and the MDS documented the resident as cognitively intact with a BIMS score of 14 and needing moderate to substantial assistance with most ADLs. The discharge was planned and documented as a transfer to another SNF for resident preference, but the discharge summary did not include the reconciled medication list or care plan, and the record lacked follow-up documentation supporting the discharge planning discussions noted by staff.
Pest Control Program Failed to Keep Facility Free of Mice, Spiders, and Insects
Penalty
Summary
The facility failed to provide an effective pest control program to keep the building free from mice, spiders, and other insects. The facility policy required a written agreement with a qualified outside pest service and use of appropriate indoor and outdoor pest control methods, but survey observations and interviews showed ongoing pest activity throughout the facility. During the survey, a kitchen alleyway door was observed propped open when not in use, a gap was seen under an emergency exit door with daylight visible through it, and spiders were observed in hallways and near exit doors. Sticky traps and mousetrap boxes were also observed in resident areas, with some traps containing spiders, bugs, and mouse droppings. Resident interviews documented repeated reports of pests in rooms and common areas. One resident reported seeing spiders every day and said there had previously been an ant issue. Another resident reported seeing a mouse in the room two days earlier, and mouse droppings were observed by the window sill and under the sink during the interview. Other residents reported spiders on beds, large spiders under beds and on walls, mouse droppings in rooms, and insects crawling across floors. In a group interview, residents reported spiders in rooms, recent spider bites, and mice running through rooms and hallways. Resident council minutes from December 2025 through May 2026 documented an ongoing mouse problem, with continued use of traps and daily checks, but did not show that the problem had been resolved. Pest control invoices showed that the pest control company repeatedly identified open doors and door gaps as issues and recommended repairs, sealing gaps, and keeping doors closed when not in use. The invoices also documented that these concerns remained open across multiple visits. Despite these recommendations, survey observations still found the kitchen alleyway door propped open and a gap under an exterior emergency exit door. Staff interviews confirmed that spiders and mice had been seen in the facility, that residents had complained about pests, and that the maintenance director had focused on traps and routine pest service while missing the pest control company’s notes about door openings and gaps.
Improper Medication Labeling, Expired Drugs, and Unsecured Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled, stored, and secured in accordance with accepted professional standards. Surveyors found that medications in two medication carts and two storage closets were not consistently labeled with open dates, expired medications remained in use areas, and medication and chemical storage areas were not secured as required. On the west hallway medication cart, surveyors observed one box of diphenhydramine 25 mg expired in May 2026, one box of single-use Genteal Tears with two expiration dates listed as January 2026 and February 2026, and four opened bottles of latanoprost 0.005% with no open dates. On the same cart, surveyors also found five bottles of Refresh Tears 0.5% with no open date, three bottles of latanoprost 0.005% with no open date, one bottle of milk of magnesia expired in October 2025, one bottle of magnesium oxide 400 mg with no expiration date, one Humalog insulin pen with no open date, and one Lantus insulin pen with no open date. Staff told surveyors that eye drops and insulin pens should be labeled with open dates, and the DON stated that medications with shortened expiration dates should be labeled once opened so expired medications are not administered. Surveyors also found unsecured storage areas. A medication storage closet on one unit, located in the main hallway next to residents’ rooms, had a lock but was not locked and contained two baskets with ten heparin syringes, five large bags of IV fluid, and IV starting kits. The East unit medication storage room, also located in a hallway next to residents’ rooms, was unlocked and contained wound care supplies, personal care supplies, vinegar solution, soap, disinfecting wipes, hand sanitizers, and multiple bottles of whirlpool disinfectant. The DON stated that heparin and IV solutions are medications and should not be kept in unlocked storage, and that the East unit storage room should always be locked because it contained chemicals accessible to residents.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one resident reviewed for antibiotic stewardship. Resident #30 was admitted with diagnoses including chronic kidney disease and a history of recurrent UTIs, and the 6/16/26 MDS showed the resident was cognitively intact, incontinent of bowel and bladder, and receiving antibiotics. The June 2026 MAR showed the resident was receiving cephalexin 250 mg every day for UTI prophylaxis, started on 1/2/26. Record review showed a provider note on 1/2/26 documenting that the resident requested prophylactic antibiotic use because she had reportedly been on it for years and had a bladder pouch that caused recurrent bladder infections; the provider verified the cephalexin and ordered it every evening. An NP note documented education about the potential for MDRO development with long-term antibiotic use, but the resident refused to discontinue. During interviews, the IP could not locate documented rationale for the long-term antibiotic use and said it was missed and not documented. RN #2 said she did not know why the resident was on antibiotics and found no signs or symptoms of UTI or ongoing acute infection. NP #1 said the long-term antibiotic use was, to his knowledge, prescribed by a urologist, but no additional urology documentation was provided or found in the record.
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Compliance trends in Colorado
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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