Based on record review, staff interviews, and the facility policy titled Pharmacy Services and Medication Regimen Review (MRR), the facility failed to ensure that one of nine residents (R) (R1) was free from an unnecessary medication related to an excessive dose of Methotrexate Sodium tablets. Specifically, the facility administers Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's… …
F757 · Unnecessary drugs
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F757 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F757 finding.
The harm level
How severely F757 is cited
1.5% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J190.5% | K60.2% | L— |
| Actual harm | G270.8% | H— | I— |
| No harm, potential for more than minimal | D2,95683.8% | E51414.6% | F10.0% |
| No harm, potential for minimal | A— | B20.1% | C10.0% |
In the surveyor’s words
What an F757 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on clinical record review and staff interviews, the facility failed to ensure that the drug regimen of 1 of 2 residents reviewed, Resident #1, was free from unnecessary drugs. Specifically, Resident ID #1 was prescribed Lovenox (an anticoagulant medication prescribed to prevent and treat harmful blood clots) and was administered more than twice the intended dose due to the facility's failure to ensure the medication dosage was accurately ordered, verified, and administered. As a result of this medication error, Resident ID #1 sustained actual harm, including bruising, pain, and swelling of the left arm, which required hospitalization. …
Greenville Operations RI LLC DBA Greenville Skille · Rhode Island
Based on interview and document review, the facility failed to adequately monitor possible side ffects for 1 of 5 residents (R15) reviewed for unnecessary medications.Findings Include:R15's quarterly Minimum Data set (MDS) dated [DATE], identified R15 was cognitively intact, with diagnoses which included anxiety, depression and bi-polar (manic and depressive episodes) disease. R15's MDS also identified R15 received antipsychotic, antianxiety, and antidepressant medications.R15's care plan revised 7/29/26, identified R15 had depressive disorder, insomnia, anxiety, post-traumatic stress disorder (PTST), and bipolar. …
Based on interview and medical record review, the facility failed to provide adequate monitoring of the blood pressure to ensure one of 18 final sampled residents (Resident 341) was free from the unnecessary drugs. * The facility failed to ensure Resident 341's blood pressures were checked prior to administering metoprolol (antihypertensive medication) as prescribed by the physician. This failure had the potential to negatively affect Resident 341's health condition and well-being. Findings: Medical record review for Resident 341 was initiated on 12/3/24. …
By state — 2025
Where F757 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Kansas4.46× · 59 citations
- Maryland1.94× · 47 citations
- Washington1.58× · 36 citations
- Florida1.56× · 38 citations
- Ohio1.54× · 79 citations
- Indiana1.38× · 39 citations
- Minnesota1.37× · 28 citations
- Wisconsin1.28× · 28 citations
- California1.10× · 138 citations
- Michigan0.90× · 27 citations
- Pennsylvania0.59× · 31 citations
- Texas0.55× · 42 citations
Co-occurrence
Cited alongside F757
Of the 2025 surveys that cited F757, these tags appeared in the same inspection more often than chance would predict.
- F88112.6% of F757 surveys · 6.3× chance
Implement a program that monitors antibiotic use.
- F75618.5% of F757 surveys · 5.7× chance
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- F60514.3% of F757 surveys · 4.9× chance
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- F75812.5% of F757 surveys · 4.8× chance
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- F6996.5% of F757 surveys · 4.8× chance
Provide care or services that was trauma informed and/or culturally competent.
Cited in the same inspection, not caused by one another.
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