F759 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F759 more often than its own record predicts
Versus expected share1.51×
1.51 times the share F759 takes of citations nationally.
Share of California citations1.63%
Of every deficiency written in California in 2025, this is the portion that was F759.
California1.63%
National1.08%
Share of all citations that were F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F759 findings written in California, 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.
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. …
E · No harm, potential for more than minimal, patternSeptember 2, 2026
Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 1 of 2 sampled residents (Resident 100), when:1. A licensed nurse administered an incorrect dose of lovenox (medication used as a blood thinner) not according to the Physician's Order.2. A licensed nurse administered a dose of hydrocodone-acetaminophen (combination of two medications used for pain) 5/325 mg (milligram, unit of measure) for a pain level of zero against the Physician's Order.As a result, 2 errors were identified out of 28 opportunities for error during the observation of medication administration; the facility medication error was 7.14%.Findings: 1. …
B · No harm, potential for minimal, patternAugust 5, 2019
Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. One of three licensed nurses (LVN 1) who administered the medications was found to have errors.
* LVN 1 failed to administer the medications with meals and before breakfast according to the physician's orders [REDACTED].
Findings:
On 9/18/19 at 0846 hours, an observation of Resident 86's medication administration was conducted with LVN 1.
LVN 1 was observed preparing and administering Resident 86's medications by mouth, including:
- carvedilol (blood pressure medication) 20 mg, one tablet; however, review of the physician's orders [REDACTED]. …
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