Based on observation, interview, and record review, the facility did not ensure medication error rates are not 5% or greater. Surveyor observed 4 errors out of 20 opportunities for an error rate of 20% during medication administration affecting 3 of 4 residents (R) reviewed (R5, R6, and R17).-Registered Nurse (RN) O did not prime R5's insulin pen prior to administration.-RN O administered the wrong dose of Bio freeze gel medication to R5.-Licensed Practical Nurse (LPN) H was attempting to administer insulin to R6 without an open or expiration date.-LPN H administered Midodrine to R17 without following physician orders to check blood pressure prior to administering the medication.This is evidenced by:The facility policy titled, Administering and Documentation of Medication Administration,… …
F759 citations in Wisconsin
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
Wisconsin cites F759 more often than its own record predicts
1.05 times the share F759 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F759 findings written in Wisconsin, 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 Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 1.95% | 1.59× |
| 2024 | 1.54% | 1.43× |
| 2025 | 1.13% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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