Based on interview, record review, and facility policy review, the facility failed to prevent significant medication errors for 2 out of 7 residents (R1 and R4) reviewed for medication administration out of a total sample of 15 residents. R1 was administered medications prescribed for R2 on 04/16/25. This medication error caused R1 to be transferred to the hospital due to an accidental medication overdose. The facility's failure to prevent significant medication errors, continually assess the resident after the medication error, and immediately notify the physician of the medication errors created a finding of immediate jeopardy that began on 4/16/25. Surveyor notified the Administrator and Assistant Director of Nursing (ADON) of the immediate jeopardy on 6/5/25 at 10:20 AM. …
F760 citations in Wisconsin
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
Wisconsin cites F760 more often than its own record predicts
1.21 times the share F760 takes of citations nationally.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F760 findings written in Wisconsin, 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 and record review, the facility did not ensure that Residents were free of significant medication errors for 1 (R1) of 6 sampled residents. The facility failed to ensure a prescribed weekly Methotrexate regimen was accurately entered, verified, and administered according to the prescriber's intended frequency for R1. Evidenced by: Review of R1's discharge MDS (minimum data set), with an ARD (Assessment Reference Date) of 07/14/26, indicates R1 was admitted to the facility on [DATE] with diagnoses including arthropathic psoriasis, Type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, polyneuropathy, restrictive lung disease, and recent right conversion total hip arthroplasty with hardware removal performed on 04/09/26. …
Based on interview and record review, the facility did not ensure 1 resident (R1) of 13 sampled residents was free of significant medication errors. R1 did not receive medications as ordered when the facility did not obtain updated orders after their wound care appointment. Findings include: The facility's Administering Medications policy, revised October 2023, indicates: Medications are administered in a safe and timely manner and as prescribed .4. Medications are administered in accordance with the prescriber order, including any required time frame . On 8/17/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including methicillin-resistant Staphylococcus aureus (MRSA) and an open-to-the-bone toe wound. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.95% | 0.85× |
| 2024 | 1.15% | 0.99× |
| 2025 | 1.57% | 1.21× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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