F759: Ensure medication error rates are not 5 percent or greater
F759 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Ensure medication error rates are not 5 percent or greater.
It sits in CMS's pharmacy service category.
CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.
How seriously inspectors rate it
Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 12.7% of F759 citations came from a complaint visit rather than a routine inspection.
By letter: D 3,381, E 1,430, F 5, J 1, K 4, L 1.
What inspectors wrote
Three recent F759 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.
Inspectors wrote, August 13, 2026, scope and severity DBased upon observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. 28 medication opportunities were observed with 3 errors occurring, for a total medication error rate of 10.71 percent.
Shores Nursing and Rehab Center, Port Saint Joe, FL
Inspectors wrote, July 31, 2026, scope and severity EBased on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Residents 121 and 136).
Centre Care Rehabilitation and Wellness Services, Bellefonte, PA
Inspectors wrote, July 30, 2026, scope and severity DBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, which involved 1 of 5 residents (Resident #6) and 1 of 3 staff (LVN F) observed during medication administration reviewed for medication error. The facility failed to ensure LVN F mixed each crushed medication with water and administered one medication at a time through Resident #6's g-tube. This failure could place residents at risk of medication interactions leading to an altered therapeutic response.
White Settlement Nursing Center, White Settlement, TX
Most recent F759 citations at the harm or jeopardy level
Newest first, all 6 in the current files. Each home's page shows the citation in full context, with its correction status.
| Inspection | Home | Town | Letter | Visit |
|---|---|---|---|---|
| January 2, 2026 | Providence St. Elizabeth Care Center | North Hollywood, CA | K | Standard |
| October 4, 2024 | Providence St. Elizabeth Care Center | North Hollywood, CA | J | Standard |
| June 11, 2024 | Cottage Crest Post Acute | Norwalk, CA | K | Standard |
| February 4, 2024 | Manchester Healthcare Center | Los Angeles, CA | L | Standard |
| October 20, 2023 | All Saints Healthcare Subacute | North Hollywood, CA | K | Standard |
| March 14, 2022 | California Post Acute | Los Angeles, CA | K | Standard |
Most recent F759 citations
F759 citations by state
Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.
| State | Citations |
|---|---|
| California | 904 |
| Texas | 378 |
| Ohio | 370 |
| Florida | 317 |
| Missouri | 308 |
| Illinois | 288 |
| Michigan | 154 |
| Wisconsin | 140 |
| Massachusetts | 126 |
| Pennsylvania | 114 |
| New Jersey | 112 |
| Maryland | 111 |
| Georgia | 101 |
| Virginia | 94 |
| North Carolina | 90 |
| Indiana | 87 |
| Colorado | 81 |
| Nebraska | 80 |
| Washington | 80 |
| New York | 73 |
| South Carolina | 63 |
| Oklahoma | 61 |
| Oregon | 58 |
| Louisiana | 55 |
| Arkansas | 53 |
| Nevada | 46 |
| Iowa | 44 |
| Minnesota | 41 |
| Tennessee | 41 |
| Kentucky | 33 |
| Kansas | 32 |
| Mississippi | 31 |
| Connecticut | 27 |
| New Mexico | 27 |
| Arizona | 23 |
| Montana | 21 |
| North Dakota | 20 |
| Utah | 20 |
| Rhode Island | 18 |
| Idaho | 16 |
| West Virginia | 13 |
| Alabama | 12 |
| New Hampshire | 12 |
| South Dakota | 11 |
| Hawaii | 9 |
| Vermont | 8 |
| Delaware | 5 |
| Maine | 5 |
| Alaska | 4 |
| District of Columbia | 3 |
| Wyoming | 2 |
By inspection year: 2018 16, 2019 123, 2020 60, 2021 186, 2022 380, 2023 900, 2024 1,306, 2025 1,169, 2026 682.
Common questions
- What is F759 in a nursing home inspection?
- F759 is the federal requirement to "ensure medication error rates are not 5 percent or greater". CMS files it under pharmacy service. A home cited under F759 did not meet that requirement at the inspection.
- How often is F759 cited?
- The CMS files as of September 1, 2026 list 4,822 F759 citations at 3,881 nursing homes, 934 of them in the 12 months to that date. 0.1% were rated as actual harm or immediate jeopardy.
- Is a F759 citation serious?
- It depends on the letter. Most F759 citations (99.9%) were rated as potential for more than minimal harm, D to F. 6 were immediate jeopardy, the most serious level.
The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology