Based on document review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, to ensure he/she was free from a significant medication error when the Resident's immunosuppressant medication was discontinued in error. As a result, Resident #40 missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization . …
F760 citations in Massachusetts
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
Massachusetts cites F760 less often than its own record predicts
0.95 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F760 findings written in Massachusetts, 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 records reviewed and interviews for one of three sampled residents (Resident #1), who required 1) anticonvulsant medication for epilepsy (seizure disorder) and 2) an anticoagulant (blood thinner) for a newly diagnosed deep vein thrombosis (DVT, blood clot), the Facility failed to ensure he/she was free from a significant medication error, when upon re-admission to the facility, his/her medication orders were not accurately reconciled by nursing resulting multiple missed doses of both medications. …
Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required daily administration of a diuretic and had been newly admitted from an acute care setting, the Facility failed to ensure he/she was free from a significant medication error, when his/her medication orders were not transcribed correctly by nursing, his/her Furosemide (diuretic) 80 milligrams was omitted and as a result, he/she was not administered his/her diuretic three days in a row.Findings include:The Facility Procedure, titled Incidents and Accidents, dated 01/30/24, indicated an incident was defined as an occurrence or situation that was not consistent with the routine care of a resident, and included medication errors. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 1.29% | 1.16× |
| 2024 | 1.07% | 0.92× |
| 2025 | 1.23% | 0.95× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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