Based on a review of clinical records, select facility policies, documentation provided by the facility, observations, and staff interviews, it was determined the facility failed to ensure residents were free of significant medication errors and failed to implement effective procedures to accurately identify residents prior to medication administration. This failure resulted in an Immediate Jeopardy situation when a nurse administered a narcotic medication (morphine sulfate) prescribed for Resident 50 to Resident 51, causing profound bradycardia (abnormally slow heart rate) requiring emergency transfer to the hospital and administration of naloxone (a medication that reverses the effects of opioid overdose) on two occasions. …
F760 citations in Pennsylvania
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
Pennsylvania cites F760 less often than its own record predicts
0.91 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F760 findings written in Pennsylvania, 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 review of facility policy, clinical record, facility documentation, and staff interview, it was determined the facility failed to ensure that one of three residents (Resident R1) were free from significant medication errors which resulted in actual harm requiring increased monitoring and intravenous placement, and administration of replacement fluids to increase blood pressure for one of two residents (Resident R1).Findings include: Review of the facility policy Medication Administration dated 3/25/26, with a previous review date of 3/26/25, indicated that medications are to be administered safely and following state and federal regulations. Residents are to be identified utilizing a name band and or photo before administration of medications. …
Based on review of policy, review of clinical record, and interviews with resident and staff it was determined that facility failed to ensure one resident was free from a significant medication error for one of two residents reviewed (Resident R1).Findings Include: Review of facility policy Pharmacy Services facility reviewed January 20, 2026, states that the provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including but not limited to: provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 1.14% | 1.03× |
| 2024 | 0.83% | 0.71× |
| 2025 | 1.18% | 0.91× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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