Healthcare Facility Inspection of the VA Eastern Colorado Health Care System in Aurora

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Date Issued

Tuesday, February 24, 2026

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

25-00200-48

Report Description

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Eastern Colorado Health Care System in Aurora.

This evaluation focused on five key content domains:
•    Culture
•    Environment of care
•    Patient safety
•    Integrated veteran care
•    Veteran-centered safety net

The OIG issued 10 recommendations for VA to correct identified deficiencies in three domains:
1.    Environment of care
•    Liquid nitrogen storage
•    Expired supplies
•    Multidose medication labels
•    Clean and dirty storage
•    Repeat findings
2.    Patient safety
•    Test result communication policy and workflows
•    Radiology staffing
•    Community care imaging results
•    Root cause analyses
3.    Primary care
•    Staffing and panel sizes

Report Type

Inspection / Evaluation

Location

CO
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/healthcare-facility-inspection/healthcare-facilit…

Open Recommendations

This report has 9 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.
02	No	$0	$0
Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.
03	No	$0	$0
Facility leaders ensure staff label opened multidose medications with expiration dates.
04	No	$0	$0
Facility leaders ensure staff store clean and dirty items separately.
05	No	$0	$0
The Director ensures staff implement processes to prevent repeat environment of care findings.
06	No	$0	$0
The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.
07	No	$0	$0
Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.
08	No	$0	$0
Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.
09	No	$0	$0
Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.