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 citations in Georgia
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
Georgia cites F757 less often than its own record predicts
0.29 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia 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 Georgia surveyors wrote
F757 findings written in Georgia, 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 interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (R15) was free from unnecessary psychotropic medications. Resident (R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. …
Based on record review, staff interviews, and review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to ensure antibiotic medications were not administered unnecessarily for two of five sampled residents (R) (R92 and R10) reviewed for unnecessary medications. This deficient practice had the potential to cause adverse drug reactions, medication interactions, and the development of multidrug-resistant organisms (MDROs).Findings included:1. A review of the Electronic Health Record (EHR) for R92 revealed she was admitted on [DATE] with a most recent readmission date of 4/7/2025 with diagnoses included, but not limited to, vascular dementia with psychotic disturbance, delirium due to a known physiological condition, urinary retention, cerebrovascular disease,… …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 0.21× |
| 2024 | 0.34% | 0.48× |
| 2025 | 0.23% | 0.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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