Based on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significant medication error that resulted in opioid overdose and hospitalization in an intensive care unit, requiring administration of Narcan (a life-saving opioid-reversing medication). In addition, the facility failed to ensure correct medication administration documentation for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for medication errors. On 08/14/2025 at 2:37 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.45(f)(2), F760, Free of any significant medication errors, related to the facility's failure to ensure that a resident (Resident 1) was not subject to significant medication errors. …
F760 citations in Washington
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
Washington cites F760 more often than its own record predicts
1.10 times the share F760 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F760 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 prevent significant medication errors by administering medications to the wrong resident for 1 of 3 residents (Resident 1) reviewed for medication errors. Resident 1 experienced harm when they were transferred to the hospital for a life-threatening medication overdose requiring life support. This failure placed residents at risk for negative side effects of medications, hospitalization, and a diminished quality of life. …
Based on interview and record review, the facility failed to transcribe provider orders correctly and administer medication as intended by the provider for 1 of 3 sampled residents (Resident 1), reviewed for unnecessary medications. This failure placed residents at risk of adverse side effects and unnecessary medications. Findings included .According to the 06/01/2026 admission assessment, Resident 1 was admitted with diagnoses to include heart and lung disease. The resident had memory impairments and difficulty verbalizing their needs. Review of the 05/26/2026 admission orders showed the Resident 1 had been taking Prednisone (a steroid that reduces swelling in order to treat a condition) 60 milligrams (mg) daily. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.81% | 0.73× |
| 2024 | 1.16% | 0.99× |
| 2025 | 1.43% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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