Based on resident and staff interviews and record review, facility staff failed to ensure that Resident #1 was free of unnecessary antipsychotic drugs. On (MONTH) 18, 2019, at 6:10 PM an Immediate Jeopardy (IJ)-K was identified at CFR§ 483.45 (d) (4), F758. On (MONTH) 18, 2019 at 7:05 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, as follows: 1. A review of all residents in the facility to ensure that there is an appropriate [DIAGNOSES REDACTED]. 2. Education to all staff to ensure that residents have appropriate [DIAGNOSES REDACTED]. 3. The nurse managers and supervisors will continue to randomly audit 20% of physician orders [REDACTED]. Record Review Resident #1was admitted to the facility on (MONTH) 26, (YEAR). …
F758 citations in District of Columbia
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.
No F758 citations were recorded in District of Columbia for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What District of Columbia surveyors wrote
F758 findings written in District of Columbia, 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 observation, record review and staff interview, for one (1) of 60 sampled residents, the facility staff failed to attempt a gradual dose reduction for a resident who used [MEDICATION(S)] (antidepressant) HCL (hydrochloride) SR (sustain released tablet) daily for depression. Resident #123. The findings included: During observations from 07/19/2021 to 07/29/2021, Resident #123 was observed in her room, alert, oriented to name, place, time, very pleasant watching movies and interacting with staff. Resident #123 was admitted to the facility on [DATE]. The medical record revealed the resident had multiple diagnoses including Major Depression. Review of the physician ' s order dated 02/12/2021, ordered, [MEDICATION(S)] HCL SR 150 milligrams by mouth one time a day for depression. …
What else District of Columbia surveyors cite →
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