Based on closed medical record review, hospital record review, drug information review, review of the American Heart Association Journal at ahajournals.org, review of the facility policy Anticoagulant Therapy and interview, the facility failed to ensure anti-coagulant medication was monitored to ensure it was administered at a therapeutic dose and timely held in the presence of adverse consequences. This resulted in Immediate Jeopardy and actual harm beginning on [DATE] when Resident #44, who had a history of atrial fibrillation and an artificial heart valve managed with the anticoagulant medication, Coumadin (warfarin) and had been diagnosed and treated for a subdural hematoma prior to her admission to the facility, was ordered to resume her Coumadin at a higher dose than previously… …
F757 citations in Ohio
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
Ohio cites F757 more often than its own record predicts
1.54 times the share F757 takes of citations nationally.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F757 findings written in Ohio, 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 medical record review, emergency medical service and hospital record review, interview, policy review and review of nursing standards of practice, the facility failed to ensure Resident #58 was free of unnecessary medication without adequate monitoring. This affected one (#58) of three residents reviewed for medication errors. The facility census was 61. Actual Harm occurred on 10/26/25 when Resident #58, a resident with a known low heart rate requiring cardiovascular medications to be held due (due to low heart rate) was administered four cardiovascular medications resulting in the resident becoming unresponsive one hour after medication administration. …
Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure an anti-nausea medication ordered to be administered as needed was given to a resident with adequate indications for use. This affected one resident (Resident #1) of four reviewed for medication administration. The facility census was 75. Findings include:Review of Resident #1's medical record revealed an admission date of 07/30/25 with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, generalized anxiety disorder, and suicidal behavior.Review of Resident #1's care plan revised 05/14/26 revealed Resident #1 had alterations in mood and behaviors related to diagnoses of bipolar disorder, anxiety, history of… …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 1.25% | 1.56× |
| 2024 | 1.16% | 1.66× |
| 2025 | 1.23% | 1.54× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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