Based on interview and record review it was determined the facility failed to ensure Staff 5 (Former Staff/RN) had the appropriate skills and competencies necessary to care for resident needs related to medication administration. This failure resulted in Resident 1 receiving Resident 2's [MEDICATION(S)] (narcotic pain medication). Resident 1 had an allergy to [MEDICATION(S)]. Resident 1 experienced respiratory distress, hospitalization and death. This constituted an immediate jeopardy situation. Findings include: a. …
F726 citations in Oregon
Competent nursing staff · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F726 less often than its own record predicts
0.17 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F726.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F726 findings written in Oregon, 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.
1. Based on interview and record review it was determined the facility failed to ensure the licensed nursing staff had the appropriate competencies and skill sets to provide nursing care for a resident with a PleurX Catheter (a small, flexible tube that doctors place within the patient's chest to drain fluid from the pleural space) for 1 of 3 sampled residents (#5) reviewed for hospice. This caused Resident 5 to have increased pain, shortness of breath, psychosocial harm and experienced sustained a distressing and diminished quality of life prior to death. Finding include: Resident 5 admitted to the facility on [DATE] with diagnoses including heart failure and chronic pleural effusion (an excessive accumulation of fluid in the lungs pleural space). …
Based on observation, interview and record review it was determined the facility failed to ensure licensed nurses were certified in and proficient with Basic Life Support (BLS) for 10 of 21 licensed nursing staff (#s 3, 8, 28, 31, 43, 44, 45, 46, 47, 48) reviewed for Cardio-Pulmonary Resuscitation (CPR). This placed residents at risk for not receiving full life-saving measures. Findings include:The 2025 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Adult Basic Life Support Algorithm indicated to send someone to get the AED after checking patient responsiveness and activating the emergency response system (call 911), and to use AED as soon as it is available. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.13× |
| 2024 | 0.61% | 0.92× |
| 2025 | 0.10% | 0.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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