Based on interview and record review the facility failed to ensure the facility's consulting pharmacist (PH) conducted monthly and as needed Drug Regiment Reviews ([DRR]thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and made recommendations for gradual dose reduction ([GDR] - tapering mediation dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) or medication dosage adjustments to control behavioral symptoms for two of two… …
F758 citations in California
Psychotropic drugs · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F758 more often than its own record predicts
1.39 times the share F758 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F758.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F758 findings written in California, 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.
A.Based on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for two of five sampled residents (Resident 22, and Resident 6) by: A1. Failing to ensure one of two sampled residents (Resident 22) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 22. A2. Failing to ensure one of two sampled residents (Resident 6) did not receive routine and as needed psychotropic drugs unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 6. …
Based on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 19) when: 1.Quetiapine (medication used to treat mental illness characterized by disordered thinking, hallucination) was administered without implementing resident-centered non pharmacological interventions prior to administration of the medication; and 2. There was no attempt for gradual dose reduction (GDR - process of slowly and systematically decreasing the dosage of a medication, particularly psychotic medication) with the use of quetiapine. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.76% | 1.06× |
| 2024 | 1.78% | 1.20× |
| 2025 | 0.88% | 1.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction