Based on observation, interview, and record review, the facility failed to ensure residents were monitored for target behaviors, monitored for side effects, and educated on the risks/benefits of psychotropic use prior to initiation for 1 of 3 residents (R1) reviewed for unnecessary medications. This deficient practice caused actual harm when R1 experienced a decline in condition following the initiation and continued increase of a psychotropic medication. Findings include: R1's admission Minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE]. R1 had minimal difficulty in some environments with hearing, clear speech, and impaired vision, could see large print only. R1 sometimes understood others and responded adequately to simple, direct communication. …
F758 citations in Minnesota
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
Minnesota cites F758 more often than its own record predicts
1.97 times the share F758 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F758 findings written in Minnesota, 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 interview and document review, the facility failed to ensure target behaviors were consistently monitored for 5 of 5 residents (R7, R28, R30, R46, R1) reviewed for unnecessary psychotropic medication use. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], indicated R7 admitted to the facility on [DATE], had severe cognitive impairment, and diagnoses included dementia, delusional disorders, and depression. R7's order summary, printed 4/25/25, indicated R7 had the following psychotropic medication orders: lorazepam concentrate (antianxiety) 0.25 mL (0.5 mg) twice a day (BID) for anxiety disorder quetiapine (antipsychotic) 25 mg daily for dementia with other behavioral disturbance Sertraline (antidepressant) 100 mg daily for dementia with other behavioral… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 2.32% | 1.41× |
| 2024 | 2.68% | 1.80× |
| 2025 | 1.24% | 1.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota 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