Based on observation, record review, and staff interview, the facility failed to ensure an error rate of less than five (5) percent. Two (2) errors were observed in 29 medication administration opportunities to give an error rate of 6.9 percent. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of medication administration. Resident Identifiers: #14 and #60. Facility Census: 88. Findings included: a) Resident #14 On 07/15/2026 at 8:00 AM, Licensed Practical Nurse (LPN) #77 was observed preparing morning medications for Resident #14. LPN #77 crushed the resident's medications and placed them in applesauce. Among the medications crushed was enteric coated aspirin, 325 milligrams (mg). …
F759 citations in West 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
West Virginia cites F759 less often than its own record predicts
0.08 times the national share — cited less often here than elsewhere.
Of every deficiency written in West 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 West Virginia surveyors wrote
F759 findings written in West 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 West Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 0.14× |
| 2024 | 0.15% | 0.14× |
| 2025 | 0.09% | 0.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West 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