F759 in Kentucky. Pick another state for the same tag.
Against expectation — 2025
Kentucky cites F759 more often than its own record predicts
Versus expected share1.55×
1.55 times the share F759 takes of citations nationally.
Share of Kentucky citations1.68%
Of every deficiency written in Kentucky in 2025, this is the portion that was F759.
Kentucky1.68%
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 Kentucky surveyors wrote
F759 findings written in Kentucky, 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.
J · Immediate jeopardy, isolatedJuly 20, 2018
Based on observation, record review, interview, and policy review, and the Geriatric Dosage Handbook, 12th Edition, it was determined the facility failed to ensure the medication error rate was not five (5) percent or greater. The facility failed to evaluate the competency and skill level of License Practical Nurse (LPN) #9 when the LPN was hired (05/22/18), during the orientation process, or after being notified by orientation staff that LPN #9 was not following standards of practice related to medication administration.
On 06/04/18, LPN #9 administered Insulin (diabetic medication) in error to Resident #21 resulting in a significant medication error. No formal retraining or counseling was provided to LPN #9 after the error. …
E · No harm, potential for more than minimal, patternMay 21, 2026
Based on observation, interview, record review, facility policy review, and manufacturer guideline review, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 6 medication errors out of 25 opportunities affecting 6 (Residents 8, 66, 19, 38, 51, and 22) of 8 residents reviewed during the medication administration task, resulting in a medication error rate of 24%.Findings included: A facility policy titled, Insulin Administration, revised 01/05/2025, revealed, Prime the insulin pen by removing air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. …
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