Based on interview and record review conducted during a survey, the facility failed to ensure that residents were free of significant medication errors for one (1) (Resident #1) of three (3) residents reviewed for medication errors. Specifically, on 02/23/2026 Licensed Practical Nurse #1 pre-poured 20 residents' medications and administered medications to Resident #1 that were intended for Resident #2. Resident #1 later became difficult to arouse, developed hypotension (low blood pressure), bradycardia (heart beat fewer than 60 times per minute), and a lower respiratory rate which required the administration of Narcan (naloxone, medication used to reverse opioid overdoses). …
F760 citations in New York
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
New York cites F760 more often than its own record predicts
1.13 times the share F760 takes of citations nationally.
Of every deficiency written in New York 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 New York surveyors wrote
F760 findings written in New York, 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 interviews and record review, the facility failed to ensure residents were free of significant medication errors for one of three residents reviewed (Resident #1). Specifically, Resident #1 received multiple doses of an anti-Parkinsonism medication (used to treat symptoms of Parkinson's disease) in error resulting in Resident #1 requiring hospitalization for an accidental overdose. Subsequently, Resident #1 experienced a decline in their physical functioning that required additional therapy services. This resulted in actual harm that was not Immediate Jeopardy for Resident #1. …
Based on record review and interviews conducted during an Abbreviated Survey, the facility did not ensure that one (Resident #3) of three residents reviewed for medication administration was free of significant medication errors. Specifically, Licensed Practical Nurse #10 entered the wrong order for morphine for Resident #3 on 06/26/2026. The physician order entered by Licensed Practical Nurse #10 and transmitted to the pharmacy documented Morphine Sulfate Concentrate Solution 20 milligrams per milliliter to give 0.25 milligram by mouth every four hours as needed for pain, 0.25 milliliter (one prefilled syringe). The pharmacy dispensed and delivered Morphine 10 milligrams/0.5 milliliter oral syringes with directions to give 0.25 milligram (one syringe) every four hours as needed for pain. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 1.04% | 0.94× |
| 2024 | 1.75% | 1.50× |
| 2025 | 1.46% | 1.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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