Based on observation, interview, and record review the facility failed to ensure that its medication error rate were less than 5 percent. The facility had a medication error rate of 23.53% based on 8 out of 34 opportunities, which involved 1 of 3 Residents (Residents #126) reviewed for medication administration.The facility failed to ensure CMA E had a physician order to crush Resident #126's medications resulting in incorrect dosage form for eight of Resident #126's medications.This failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.The findings include:Record review of Resident #126's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. …
F759 citations in Texas
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
Texas cites F759 less often than its own record predicts
0.86 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F759 findings written in Texas, 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.
Based on observation, interview, and record review, the facility failed to ensure the medication error rates were not five percent (5%) or greater. There were three medication errors observed out of 26 opportunities, resulting in an 11% error rate. One (LVN A) of seven staff observed administering medications made three errors for one (Resident #362) of eleven residents observed. LVN A failed to administer Resident #362's [MEDICATION NAME] sodium (pain medication), [MEDICATION NAME] (treat muscle spasm), and duloxetine (antidepressant) at the correct time, when she administered the medications one hour and 30 minutes later than what was scheduled. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 1.45% | 1.18× |
| 2024 | 1.14% | 1.06× |
| 2025 | 0.93% | 0.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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