Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5%. There were 5 errors in 29 opportunities resulting in a 17% error rate. This placed residents at risk for adverse medication side effects. Findings include:1. Resident 20 readmitted to the facility in 7/2026 with diagnoses including diabetes.The 7/30/26 physician order indicated Resident 20 was to receive insulin lispro five units TID with meals.The manufacturer instructions for insulin lispro indicated to prime the insulin pen with two units prior to drawing up the insulin for administration.On 8/17/26 at 11:19 AM Staff 6 (RN) was observed to administer insulin lispro five units via insulin pen to Resident 20. …
F759 citations in Oregon
Medication error rate · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F759 less often than its own record predicts
0.78 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F759 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.
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.63% | 1.34× |
| 2024 | 1.29% | 1.20× |
| 2025 | 0.84% | 0.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction