Based on interview, record review, and review of other documentation as indicated, it was determined that for one (R11) out of four residents sampled for medication administration review, the facility failed to ensure that R11 was free from significant medication errors as evidenced by failing to check and monitor R11's blood sugars before meals, failing to administer ordered insulin and heparin injections. The facility's multiple failures to administer critical medications had the potential to cause a serious adverse outcome or death to R11. Due to the failures, an Immediate Jeopardy (IJ) was called on 5/8/26 at 1:24 PM. The IJ was abated on 5/9/26 at 11:59 PM. Findings include:The facility's policy titled, Medication Unavailability, effective 1/29/24, documented, . Procedure . 1. …
F760 citations in Delaware
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
Delaware cites F760 more often than its own record predicts
1.47 times the share F760 takes of citations nationally.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F760 findings written in Delaware, 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 record review and interview, it was determined that for one (R1) out of four residents reviewed for pharmacy services, the facility failed to ensure R1 was free of a significant medication error. This failure resulted in a harm in which R1 seized and was transferred to the hospital on 8/7/25 with benzodiazepine withdrawal from missing four doses of lorazepam. Based on a review of the facility's corrective actions taken and completed on 8/8/25 at 11:20 PM, it was determined that this incident was past non-compliance. Findings include:8/5/25 11:59 AM - R1's [Hospital] Discharge summary documented, . Medications at discharge. lorazepam 2 mg (milligrams) oral tablet, 1 tablet by mouth 2 times a day. Please contact PCP (primary care provider) for refill. …
Based on record review, interview and review of physician orders it was determined that for one (R11) out of six residents' sampled for unnecessary medication review the facility failed to ensure that R11's blood pressure medication was held when vital signs were below ordered parameters. Findings include:The facility policy on medication administration last updated 5/1/25 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Review of R11's clinical record revealed:9/22/25 - A physicians' order was written for R11 to receive metoprolol daily for blood pressure; hold for systolic blood pressure (SBP) less than 130 or hear rate (HR) less than 60. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 1.85% | 1.67× |
| 2024 | 1.05% | 0.90× |
| 2025 | 1.91% | 1.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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