Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free of significant medication errors for 1 of 10 sampled residents reviewed for narcotic administration, Resident (R)1. On 03/12/2026, R1 was administered 5 times the intended dose of Morphine (a schedule II opioid analgesic used to treat severe pain and misuse of the medicine can cause addition, overdose, or death) on three separate instances. R1 was pronounced dead on 03/12/2026 at 5:53 PM. The facility's failure to have an effective system to ensure residents were free from significant medication errors was likely to cause serious injury, impairment, or death to a resident. …
F760 citations in Kentucky
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
Kentucky cites F760 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F760 findings written in Kentucky, 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, record review and review of the facility's policy, it was determined the facility failed to ensure residents were free of any significant medication errors, for two (2) of thirteen (13) sampled residents, (Resident #6 and Resident #8). Resident #6 went from 05/29/2020 at 12:00 PM until 06/01/2020 at 12:00 AM without his/her routine scheduled pain medication, [MEDICATION(S)]-Acetaminophen 7.5-325 milligrams (mg), ordered to be administered every six (6) hours. Resident #8, had pain related to the fracture in his/her back and would request pain medication every six (6) hours as needed to keep the pain under control. …
Based on interviews, record review, and facility policy review, the facility failed to ensure that one of three residents (R) 49 was free from significant medication errors. The facility failed to obtain a new prescription from the provider in a timely manner resulting in the resident missing five consecutive nightly doses of a prescribed medication. The findings include: Review of the facility's policy, Pharmacy Services revised 08/14/2025, revealed, the pharmacist, in collaboration with the facility and medical director, should include within its services to develop mechanisms for communicating, addressing, and resolving issues related to pharmaceutical services. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 1.23% | 1.11× |
| 2024 | 0.60% | 0.51× |
| 2025 | 0.84% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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