Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure one of 17 residents (Resident #54) was free from unnecessary medications. Resident #54 was administered her roommate's medications in error and was transferred to hospital, where she required treatment. This indicated harm. The findings were: Resident #54 was admitted to the facility with diagnoses, including but not limited to: unspecified kidney injury, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and dementia. The MDS (minimum data set) that was completed for Resident #54 was an OBRA Admission Assessment with an ARD (assessment reference date) of 07/02/2021. …
F757 citations in Virginia
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
Virginia cites F757 more often than its own record predicts
1.15 times the share F757 takes of citations nationally.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F757 findings written in Virginia, 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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to follow medication orders for administration for one of eight residents in the survey sample, Resident #5. The findings include:For Resident #5 (R5), the facility staff failed to hold medication according to the ordered parameters. The physician orders for R5 documented in part, Metoprolol Succinate ER (extended release) (1) Oral Tablet Extended Release 24 Hour 25 MG (milligram) (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN (hypertension) hold for SBP (systolic blood pressure) <100 or HR (heart rate) <60. Start Date: 04/24/2026. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.99% | 1.23× |
| 2024 | 1.28% | 1.83× |
| 2025 | 0.92% | 1.15× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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