Based on observation, interview, and record review, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 of 26 medications administered during the observation.The findings include:On 07/29/2026 at 8:34 AM, Staff #25 was observed administering medications to Resident #9. During the medication pass, Staff #25 administered 10 medications that were due to be given at 9:00 AM, but did not administer two ordered medications, metoprolol and Jardiance, that were also due at 9:00 AM. Staff #25 stated that the medications were not in the medication cart and stated, I will give those medications by 9:45 AM. …
F759 citations in Maryland
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
Maryland cites F759 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F759 findings written in Maryland, 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 Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.76% | 0.62× |
| 2024 | 1.01% | 0.94× |
| 2025 | 0.79% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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