Based on facility policy review, record review, obserevation and interview the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 4 medication errors out of 30 opportunities affecting 4 (Residents #37, #110, #97, and #129) of 4 residents reviewed during the medication administration task, resulting in a medication error rate of 13.33%. Findings included: A facility policy titled, Administration of Medications, revised 05/06/2022, revealed, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Resident Assessment. Note the resident's history and any parameters around drug administration. 1. …
F759 citations in Tennessee
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
Tennessee cites F759 less often than its own record predicts
0.75 times the national share — cited less often here than elsewhere.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F759 findings written in Tennessee, 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 Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 0.41× |
| 2024 | 0.37% | 0.34× |
| 2025 | 0.81% | 0.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee 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