Based on observation, staff interview, record review, and facility policy review, it was determined the facility failed to a) attempt GDR of [MEDICAL CONDITION] medications, b) monitor behavioral symptoms, c) obtain informed consents for the medications, and d) identify resident specific behaviors on the care plan. This was true for 4 of 6 residents (#2, #30, #87, and #261) reviewed for unnecessary medications. This resulted in harm to Resident #261 when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple [MEDICAL CONDITION] medications. This deficient practice also had the potential for harm of other residents if they receive unnecessary [MEDICAL CONDITION] medications which were not adequately monitored. …
F758 citations in Idaho
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
Idaho cites F758 less often than its own record predicts
0.53 times the national share — cited less often here than elsewhere.
Of every deficiency written in Idaho 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 Idaho surveyors wrote
F758 findings written in Idaho, 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 review of the FDA Black Box Warning, record review, and staff interview, the facility failed to ensure the medical necessity for psychotropic medication administration. This was true for 1 of 16 residents (Resident #8) reviewed for unnecessary medications. This failure created an increased risk of mortality when residents diagnosed with dementia were prescribed antipsychotic medications. Findings include: The FDA documented elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel (an antipsychotic drug) is not approved for elderly patients with dementia related psychosis. …
The short window
Recent years
| Year | Share of Idaho citations | vs expected |
|---|---|---|
| 2023 | 1.43% | 0.86× |
| 2024 | 2.07% | 1.39× |
| 2025 | 0.33% | 0.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Idaho surveyors cite →
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