Based on observation, interview, and record review, the facility failed to ensure six out of seven residents (187, 126, 2, 181, 73, 43) were free of any potential or actual significant medication errors when: Licensed Nurse (LN) 1 prepared eight morning medications for Resident 76 including clozapine (used for schizophrenia, a distorted perception of reality), topiramate (used to treat seizures, abnormal and disruptive electrical activity in the brain), and levetiracetam (used to treat seizures) and gave the medications to LN 2 to administer. LN 2 then administered Resident 76's medications to Resident 187. …
F760 citations in California
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F760 less often than its own record predicts
0.96 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F760 findings written in California, 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 interview and record review, the facility failed to ensure prescribed medication was administered in accordance with the physician's orders for one of four sampled residents (Resident 1) when Resident 1 had an order to received Phenytoin (medication for seizures - a sudden movement of electrical activity in the brain causing shaking of the limbs and stiffening of the body) and was not administered from June 7, 2026, to June 17, 2026 (a total of 19 doses). This failure resulted in Resident 1 being transferred to an acute care hospital after experiencing seizure activity. …
Based on observation, interview, and record review, the facility failed to ensure Resident 100 was free from significant medication errors when a licensed nurse administered an incorrect dose of lovenox (medication used as a blood thinner) not according to the Physician's Order.This failure resulted in Resident 100 being at risk for bleeding.Findings:According to the Institute for Safe Medication Practices (ISMP)-a nonprofit organization dedicated to preventing medication errors, dated 2018, high alert medications are drugs that can cause serious harm or death if used incorrectly. Lovenox is classified as a high alert medication by ISMP. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.21% | 1.09× |
| 2024 | 1.13% | 0.97× |
| 2025 | 1.25% | 0.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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