Based on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for 2 of 43 sampled residents (Resident 87 and 62). The deficient practice posed a potential risk of injury or harm to the residents.Findings include: On 07/08/2026 in the morning, a medication administration pass observation was performed with 39 opportunities observed with two errors. The medication error rate was 5.13%.1) R87 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus with diabetic chronic kidney disease, and chronic congestive heart failure.On 07/08/2026 at 7:49AM, during the medication administration… …
F759 citations in Nevada
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
Nevada cites F759 more often than its own record predicts
1.36 times the share F759 takes of citations nationally.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F759 findings written in Nevada, 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 Nevada citations | vs expected |
|---|---|---|
| 2023 | 2.22% | 1.82× |
| 2024 | 2.81% | 2.62× |
| 2025 | 1.47% | 1.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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