Based on interview and record review it was determined the facility failed to notify the physician of elevated CBG results for 6 of 12 sampled residents (#s 6, 9, 18, 24, 33 and 40) reviewed for insulin administration. This failure, determined to be an immediate jeopardy situation, resulted in Resident 18 developing uncontrolled diabetes and requiring intravenous insulin administration at the hospital. Resident 33 became unresponsive and the physician provided orders for the resident to transfer to the emergency department. Residents 6, 9, 24 and 40 were placed at risk for complications related to high blood sugar. Findings include: 1. …
F773 citations in Oregon
Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Oregon cites F773 more often than its own record predicts
2.40 times the share F773 takes of citations nationally.
Of every deficiency written in Oregon in 2025, this is the portion that was F773.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Oregon surveyors wrote
F773 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 lab services were provided when ordered for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for unnecessary blood draws. Findings include:Resident 24 admitted to the facility in 9/2024 with diagnoses including diabetes and anxiety.A 12/4/25 pharmacy recommendation revealed Resident 24 received a thyroid replacement medication but a TSH (Thyroid-Stimulating Hormone) laboratory test within the last year was not located in the resident's medical record.A 12/10/25 physician order revealed an order for a fasting lipid panel, TSH and serum magnesium concentration laboratory test scheduled for 12/10/25.A review of the 12/2025 TAR revealed the task to draw labs for a fasting… …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 1.36× |
| 2024 | 0.08% | 0.69× |
| 2025 | 0.31% | 2.40× |
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