Based on observations, record review, staff interviews, review of the facility's policies titled Medication Administration; Insulin Pens, Prefilled, and package insert titled, Instructions for Use Insulin Lispro KwikPen injection, for subcutaneous use the facility failed to ensure accurate administration of medications for three of 25 medication opportunities observed, resulting in a medication error rate of 12%. This deficient practice had the potential to negatively impact residents (R) leading to complications of current health status. Findings include:Review of facility policy titled, Medication Administration revised 1/8/2026 revealed item 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. …
F759 citations in Georgia
Medication error rate · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F759 more often than its own record predicts
2.17 times the share F759 takes of citations nationally.
Of every deficiency written in Georgia in 2025, this is the portion that was F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F759 findings written in Georgia, 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.
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 0.98× |
| 2024 | 1.34% | 1.25× |
| 2025 | 2.34% | 2.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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