Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 13, 38, and 40).Findings include: The facility's medication error rate was 15.38% based on 26 medication opportunities with four errors. Observation of Resident 13's medication administration on September 1, 2026, at 8:27 AM revealed Employee 3, licensed practical nurse, administered tamsulosin (medication that relaxes the muscles in the opening of the bladder) 0.4 milligrams (mg). Further observation revealed that the blister pack (a pre-formed plastic packaging used to store pharmaceuticals) had a yellow sticker that indicated taking the medication a half hour after the same meal every day. …
F759 citations in Pennsylvania
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
Pennsylvania cites F759 less often than its own record predicts
0.49 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F759 findings written in Pennsylvania, 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 Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.70% | 0.57× |
| 2024 | 0.51% | 0.47× |
| 2025 | 0.53% | 0.49× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania 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