Based on observation, interview and record review, the facility failed to ensure there was a system that provided pharmaceutical services (including procedures that effectively dealt with serious prescription discrepancies) that assured the accurate administration of all drugs and biologicals for four of five residents (4, 14, 1, 5) reviewed for safe and accurate medication practices. Resident 4 was harmed when they were administered 20x the intended dose of Oxycodone (a strong pain medication that affects mood/behavior and can be lethal in high doses) and had to be hospitalized . Several licensed nurses (LN), to include the only nurse manager, failed to verify the correct dose of the medication. …
F755 citations in Washington
Pharmacy services · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Washington cites F755 less often than its own record predicts
0.45 times the national share — cited less often here than elsewhere.
Of every deficiency written in Washington in 2025, this is the portion that was F755.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Washington surveyors wrote
F755 findings written in Washington, 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 interview and record review, the facility failed to ensure emergency medications were readily available for residents who experienced dangerously low blood sugars, medication orders in the medication administration records (MAR) used as the source for medication dosages were accurate, and all licensed staff followed safe medication practices for 4 of 5 residents (Residents 3, 1, 2, and 10) reviewed for pharmacy practices. This placed all residents at risk for ensuring emergent medications were available when needed, ensuring the accurate acquiring, dispensing, and administering of all medications. …
Based on interview and record review, the facility failed to ensure medications were available from the pharmacy as ordered for 1 (Resident 2) of 5 residents whose medication regimens were reviewed. The failure to ensure medications were available placed Resident 2 at risk for unnecessary pain and other negative health outcomes.According to the 07/23/2026 admission Minimum Data Set (MDS), an assessment tool, Resident 2 had recently undergone surgery for a leg fracture and required postoperative care, pain management, and surgical wound care.During an interview on 08/18/2026 at 3:30 PM, Resident 2 stated on the day of admission to the facility, 07/21/2026 in the late afternoon, the facility did not have their pain medication available until after 11:00 PM. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.70% | 0.33× |
| 2024 | 0.58% | 0.27× |
| 2025 | 1.05% | 0.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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