Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 4 residents observed during the medication administration (Resident #12 and Resident #46).The findings include:A review of Novolog Flex Pen manufacturer instructions stated in part, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dosage dial to 2 units, hold your NovoLog Flex Pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. …
F759 citations in North Carolina
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
North Carolina cites F759 more often than its own record predicts
1.11 times the share F759 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F759 findings written in North Carolina, 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 North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.87% | 0.71× |
| 2024 | 0.99% | 0.93× |
| 2025 | 1.20% | 1.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina 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