Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain lab testing as ordered by the medical provider for 8 of 51 sampled residents, Resident #94, Resident #2, Resident #3, Resident #5, Resident #7, Resident #8, Resident #12, and Resident #6. For Resident #94, the facility staff failed to obtain PT/INR results as ordered following the transition of Eliquis to Coumadin using a limited Lovenox bridge on four separate occasions from [DATE] through [DATE]. Lab results obtained on [DATE] and received by the lab on [DATE] resulted in a PT greater than 90 (reference range 9.60-11.33) and INR results that could not be calculated as the result greater than linearity. Resident #94 began showing signs of active bleeding on [DATE]. …
F770
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F770 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F770 finding.
The harm level
How severely F770 is cited
3.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J70.7% | K70.7% | L— |
| Actual harm | G141.5% | H10.1% | I— |
| No harm, potential for more than minimal | D80784.2% | E11111.6% | F101.0% |
| No harm, potential for minimal | A— | B10.1% | C10.1% |
In the surveyor’s words
What an F770 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interviews conducted during survey, the facility failed to obtain physician ordered laboratory tests to meet the needs of its residents for one (1) (Resident # 118) of three (3) residents reviewed. Specifically, the laboratory test ordered for Resident #118 on [DATE] and [DATE] were not completed as ordered. The laboratory test was not completed until it was ordered for a third time on [DATE], which resulted in critical levels requiring hospitalization for a blood transfusion. This resulted in actual physical harm for Resident #118 that was not Immediate Jeopardy. …
Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's order. This affected one (Resident #42) of three residents reviewed for laboratory findings. The facility census was 67. Findings include: Record review for Resident #42 revealed an admission date of 06/14/24 with diagnoses including heart failure, atrial fibrillation, hypertension, cerebral infarction and dementia. Review of Resident #42's physician's orders revealed an order dated 06/14/24 for a prothrombin time and International Normalized Ration (PT/INR), a blood test that measures how many seconds it takes for your blood to clot. …
Based on observation, interview and record review, the facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA Waiver- also known as a Medical Test Site Certificate of Waiver License, a license that allows the facility to legally perform certain simple, low risk medical tests like blood glucose checks and COVID-19 [Corona Virus Disease 2019, a respiratory illness] tests). This failure placed residents at risk for substandard care, delayed diagnosis and incorrect medical treatment. …
By state — 2025
Where F770 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Ohio1.94× · 26 citations
- California1.01× · 33 citations
Co-occurrence
Cited alongside F770
Of the 2025 surveys that cited F770, these tags appeared in the same inspection more often than chance would predict.
- F69216.0% of F770 surveys · 3.4× chance
Provide enough food/fluids to maintain a resident's health.
- F64121.3% of F770 surveys · 2.8× chance
Ensure each resident receives an accurate assessment.
- F58423.6% of F770 surveys · 2.7× chance
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F58016.4% of F770 surveys · 2.7× chance
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F76134.2% of F770 surveys · 2.6× chance
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Cited in the same inspection, not caused by one another.
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