Based on observation, record review, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 7 residents (Resident #14 and #22) observed during medication administration. Five medication errors occurred during staff administration of 26 medications, resulting in a 19% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.Findings include:The facility failed to provide a policy on medication administration, crushing medications, and obtaining/clarifying physician orders. …
F759 citations in North Dakota
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 Dakota cites F759 more often than its own record predicts
1.02 times the share F759 takes of citations nationally.
Of every deficiency written in North Dakota 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 Dakota surveyors wrote
F759 findings written in North Dakota, 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 Dakota citations | vs expected |
|---|---|---|
| 2023 | 1.75% | 1.44× |
| 2024 | 1.73% | 1.61× |
| 2025 | 1.10% | 1.02× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota 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