Based on interview, and record review , the facility failed to ensure 67 out of 67 residents (residents who received Levaquin [a brand name for levofloxacin, a type of antibiotic known as fluoroquinolone used to treat bacterial infections] and Metformin [a medication that helps control the amount of glucose (sugar) in the blood]) (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, 322, 4, 71, 80, 99, 15, 382, 2, 64, 26, 17, 380, 90, and 65) were free from unnecessary medications when there was inadequate monitoring and systemic failure in management of residents on medications with black box… …
F757 citations in California
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.
Against expectation — 2025
California cites F757 more often than its own record predicts
1.10 times the share F757 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F757.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F757 findings written in California, 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 failed to follow FDA (U.S. Food and Drug Administration) Black Box Warnings (or BBW, the most stringent safety warning required by the FDA for prescription drugs) and manufacturer specification for dosing a fentanyl transdermal patch (a powerful synthetic opioid, 50 to 100 times more potent than morphine, that is absorbed through the skin for consistent pain relief) for one of three sampled patients, Resident 1 when:1. Resident 1's fentanyl patch initiation on 11/26/25 did not follow FDA Black Box Warnings and manufacturer specification on starting dose based on history of opioid use, old age, and Chronic Obstructive Pulmonary Disease (or COPD, a long-term lung inflammation and obstruction, making it hard to breathe without medication or… …
Based on interview and record review, the facility failed to ensure a Resident was free from unnecessary drugs when one of five sampled residents (Resident 5) was on a higher than required dose of apixaban (a blood thinner medication) resulting in excessive dosing for its indication in accordance with the manufacturer's requirements.This facility failure resulted in Resident 5 being at high risk for unwanted adverse effects, such as excessive bleeding.Findings: Resident 5 was an [AGE] year-old dependent on dialysis with limited kidney function admitted to the facility from an acute care hospital.A review of Resident 5's Physician's Order, dated 5/12/26, indicated apixaban oral tablet 5 mg, to give one tablet by mouth two times a day for A-FIB (atrial fibrillation, when the heart beats in… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.84% | 1.04× |
| 2024 | 0.77% | 1.11× |
| 2025 | 0.87% | 1.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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