Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5 percent. Specifically, during 33 medication administration opportunities, two medication errors were identified for two of four residents reviewed (Resident #31 and Resident #131), resulting in a medication error rate of 6.06 percent.The findings include:The facility policy titled Medication Administration, last revised December 2019, included medications must be administered according to the orders. The individual administering medications must check the medication label three times to verify the correct dose. …
F759 citations in New York
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
New York cites F759 less often than its own record predicts
0.81 times the national share — cited less often here than elsewhere.
Of every deficiency written in New York 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 New York surveyors wrote
F759 findings written in New York, 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.
Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five percent for three (Resident's #17, and #56, and #57) of 10 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 60 percent. Findings include: Facility provided audit titled Medication Audit dated 06/24/2026-07/08/2026 for Residents #17, #56, and #57. All three residents collectively received 281 medications over one hour beyond ordered times. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 0.47% | 0.38× |
| 2024 | 0.28% | 0.26× |
| 2025 | 0.88% | 0.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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