Based on observation, interview, and document review, the facility failed to ensure a medication administration error rate of less than five percent (%). Two medication administration errors occurred out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 3 residents (R5) observed during medication pass.Finding include:Administration per Manufacturer's InstructionsR5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and had diagnoses of asthma, chronic obstructive pulmonary disease (COPD, incurable lung disease causing breathlessness, frequent coughing, and chest tightness), schizoaffective disorder, depression, central cord syndrome (spinal cord injury), chronic pain, prediabetes, and hypertension (high blood pressure).R5's Order… …
F759 citations in Minnesota
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
Minnesota cites F759 less often than its own record predicts
0.36 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F759 findings written in Minnesota, 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 Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.77% | 0.63× |
| 2024 | 0.75% | 0.70× |
| 2025 | 0.39% | 0.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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