Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 3 residents (Resident #1) reviewed unnecessary drugs. The facility failed to ensure PT/INR laboratory tests (to measure blood clotting time and thus ensure safe blood levels of the anticoagulant, warfarin) were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. …
F757 citations in Texas
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
Texas cites F757 less often than its own record predicts
0.55 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas 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 Texas surveyors wrote
F757 findings written in Texas, 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 ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #5) The facility failed to ensure Resident #5 had behavior monitoring for with the use of anti-psychotic medications. …
Based on interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs used without adequate indications for its use for 1 of 3 Residents (Resident #1) whose records were reviewed for unnecessary drugs Nursing staff failed to obtain a consent from Resident #1's RP for the use of divalproex (psychotropic medication used for anxiety). This failure could place residents at risk of the use of unnecessary medications.Findings inlcuded: Record review of Resident #1's Quarterly MDS assessment, dated 06/16/26, reflected Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE], diagnoses included unspecified mood affective disorder (a mental health diagnosis used when a person shows clear signs of significant emotional… …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.28% | 0.34× |
| 2024 | 0.36% | 0.52× |
| 2025 | 0.44% | 0.55× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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