Based on Based on interview and record review it was determined the facility failed to ensure narcotic pain medication was administered as ordered for 1 of 2 sampled residents (#1) reviewed for medication errors. This failure was determined to be an immediate jeopardy situation because Resident 1 received 100 mg of oxycodone (narcotic pain medication) rather than 5 mg as ordered twice within a four-hour period. Findings include: Resident 1 admitted to the facility on [DATE] on hospice services with diagnoses including stomach cancer, dysphagia (difficulty swallowing) and left hip fracture. …
F760 citations in Oregon
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F760 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F760 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.
Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 3 of 7 sampled residents (#s 42, 51 and 62) reviewed for medications and hospitalizations. This failure resulted in Resident 51 experiencing a ten-minute seizure and being sent to the hospital for evaluation subsequent to not receiving antiseizure medication as ordered, and placed additional residents at risk for reduced efficacy of medication and adverse side effects of medication. Findings include: 1. Resident 51 admitted to the facility in 2025 with diagnoses including depression. …
Based on observation, interview and record review it was determined the facility failed to ensure residents were free of significant medication errors for 1 of 1 sampled resident (#64) reviewed for antibiotics. This placed residents at risk for adverse side effects of an incorrect antibiotic being administered. Findings include:The facility's 1/2023 Medication Administration Policy and Procedures directed the following:-Prior to administration, review and confirm medication orders for each individual resident on the MAR.-Compare the medication and dosage schedule on the resident's MAR with the medication label. Resident 64 was admitted to the facility in 8/2026 with diagnoses including osteomyelitis (an infection and inflammation of the bone and bone marrow). …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 1.01% | 0.91× |
| 2024 | 0.91% | 0.78× |
| 2025 | 0.84% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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