of F759 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20251,170
Every F759 citation surveyors wrote nationally that year.
Facilities cited1,153
Distinct nursing homes with at least one F759 finding.
The harm level
How severely F759 is cited
0.1% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J20.0%
K40.1%
L10.0%
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D3,55070.3%
E1,48729.4%
F60.1%
No harm, potential for minimal
A—
B—
C—
Every recorded F759 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F759 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.
K · Immediate jeopardy, patternJanuary 2, 2026
Based on observation, interview, and record review, the facility failed to ensure its medication error rate was below five (5) percent (%) for two of five sampled residents (Residents 1 and 69) during the Medication Administration Facility Task conducted on 12/30/2025. The facility had seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), resulting in an overall medication error rate of 24.14%. The facility failed to:1. …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on observation, interview, and record review the facility failed to ensure that its medication error rate were less than 5 percent. The facility had a medication error rate of 23.53% based on 8 out of 34 opportunities, which involved 1 of 3 Residents (Residents #126) reviewed for medication administration.The facility failed to ensure CMA E had a physician order to crush Resident #126's medications resulting in incorrect dosage form for eight of Resident #126's medications.This failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.The findings include:Record review of Resident #126's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. …
B · No harm, potential for minimal, patternJuly 10, 2026
Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five percent for three (Resident's #17, and #56, and #57) of 10 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 60 percent. Findings include: Facility provided audit titled Medication Audit dated 06/24/2026-07/08/2026 for Residents #17, #56, and #57. All three residents collectively received 281 medications over one hour beyond ordered times. …
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Cited in the same inspection, not caused by one another.
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