Based on interview and record review the facility failed to ensure a resident's drug regimen is free from unnecessary [MEDICAL CONDITION] drugs when 1 of 11 sampled residents reviewed for antipsychotic medication (#1) received a new antipsychotic medication, [MEDICATION NAME], without documented evidence of an indication for use and in the absence of any behavioral symptoms that presented a danger to the resident or others. The resident received an excessive dose that was 80 times the ordered amount and continued to receive the excessive doses of [MEDICATION NAME] after she began experiencing adverse consequences. The resident was placed on 24-hour crisis care and was transferred to the hospital on [DATE]. Her admitting hospital [DIAGNOSES REDACTED]. …
F758 citations in Florida
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
Florida cites F758 less often than its own record predicts
0.52 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida 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 Florida surveyors wrote
F758 findings written in Florida, 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, interview, and record review, the facility failed to ensure behavior monitoring for 3 of 5 sampled residents reviewed for unnecessary medications, Residents #2, #24, and #28. The findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment. The resident was receiving antipsychotics and antidepressants. The resident was care planned for at risk for complications related to the use of psychotropic drugs: antidepressant for management of symptoms of depression and antipsychotic for management of mood disorder and Dementia. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 0.96% | 0.58× |
| 2024 | 0.69% | 0.46× |
| 2025 | 0.33% | 0.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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