Based on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of two nurses observed during a medication pass made three errors out of 27 opportunities, resulting in a medication error rate of 11.11%. Those errors impacted three Residents (#6, #27, and #60), out of nine residents observed. Specifically:1. For Resident #6, an incorrect dose of Cholecalciferol (Vitamin D3, a fat-soluble vitamin used to treat or prevent vitamin D deficiency, support bone strength with calcium, and maintain immune and muscle health) was administered;2.For Resident #60, an incorrect formula of a probiotic (live microorganisms that provide health benefits when consumed, generally by improving or restoring the… …
F759 citations in Massachusetts
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
Massachusetts cites F759 more often than its own record predicts
1.04 times the share F759 takes of citations nationally.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F759 findings written in Massachusetts, 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 Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 1.97% | 1.61× |
| 2024 | 1.07% | 0.99× |
| 2025 | 1.12% | 1.04× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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