Based on interview and document review, the facility failed to ensure laboratory results were adequately monitored and acted upon to ensure therapeutic dosing of anticoagulant medication to prevent embolism in 1 of 3 residents (R1) reviewed for unnecessary medication use. These findings constituted an immediate jeopardy (IJ) situation for R1. However, the facility had taken appropriate action(s) to correct the identified non-compliance and, as a result, the findings are being issued as past non-compliance. …
F757 citations in Minnesota
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
Minnesota cites F757 more often than its own record predicts
1.37 times the share F757 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F757 findings written in Minnesota, 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 document review, the facility failed to ensure physician ordered laboratory monitoring was completed to prevent complications and ensure therapeutic dosing for 1 of 1 residents (R4) reviewed who consumed [MEDICATION NAME] (an anti-convulsant medication) for [MEDICAL CONDITION]. This resulted in actual harm for R4 when they developed symptoms of [MEDICATION NAME] toxicity (a condition were the levels of medication in the body are too high) and were subsequently hospitalized . Findings include: R4's hospital Discharge Summary, dated 11/18/19, identified R4 had been brought to the hospital after being found obtunded (a state similar to lethargy) at her home. R4 was brought to the hospital were she was found, . …
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. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 1.03% | 1.28× |
| 2024 | 0.75% | 1.07× |
| 2025 | 1.09% | 1.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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