Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%, when two medication errors were observed for one resident (Resident #41) with a total of 25 observations, resulting in a medication error rate of 8%.Findings include:On 08/05/2026 at 2:09 PM, during medication pass observation UM D was asked what the red boarder around the medication on the resident's medication administration screen meant and he said because it was late, clarified as past the window for the scheduled administration time. The medications of midodrine hydrochloride salt 10 mg and acetazolamide 250mg both due at 1PM were administered (outlined in red). …
F759 citations in Michigan
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
Michigan cites F759 less often than its own record predicts
0.83 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F759 findings written in Michigan, 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 Michigan citations | vs expected |
|---|---|---|
| 2023 | 1.41% | 1.15× |
| 2024 | 1.13% | 1.06× |
| 2025 | 0.90% | 0.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan 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