Based on observation, staff interview, clinical record review, facility document review, and a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 26 observations resulting in a medication error rate of 7.69%. These errors affected Resident #43 and Resident #45. The findings included:For Resident #43 the facility staff failed to administer the correct dose of allopurinol. Surveyor observed licensed practical nurse (LPN) #1 during a medication pass and pour on 06/29/26 at 7:55 am. LPN #1 administered allopurinol 100 mg to the resident. Surveyor reconciled Resident #43's medications with the clinical record on 06/29/26. …
F759 citations in Virginia
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
Virginia cites F759 less often than its own record predicts
0.35 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F759 findings written in Virginia, 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 Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.32% | 1.08× |
| 2024 | 0.69% | 0.65× |
| 2025 | 0.38% | 0.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia 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