Based on surveyor observation, clinical record review, and staff interviews, the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 27 opportunities for errors observed during the medication administration task, 2 errors occurred, resulting in an error rate of 7.41% affecting Resident ID #s 128 and 133.Findings are as follows:Review of a facility policy titled, Medication Administration dated 10/11/2017, states in part, .Medications ordered to be given according to specific parameters must reflect the results of testing, i.e. [in other words] blood pressure.Prepare medications for the resident following the instructions on the MAR [Medication Administration Record].1a. …
F759 citations in Rhode Island
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
Rhode Island cites F759 less often than its own record predicts
0.96 times the national share — cited less often here than elsewhere.
Of every deficiency written in Rhode Island 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 Rhode Island surveyors wrote
F759 findings written in Rhode Island, 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 Rhode Island citations | vs expected |
|---|---|---|
| 2023 | 0.76% | 0.62× |
| 2024 | 0.89% | 0.83× |
| 2025 | 1.04% | 0.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Rhode Island surveyors cite →
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