Based on observations, review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure that one of 23 residents (Resident R92) reviewed was free of unnecessary [CONDITION(S)] medications which resulted in actual harm to Resident R92 receiving an excessive dose of an antidepressant medication, experiencing a withdrawn mood and a fall incident. Finding include: Review of facility policy title, Use of Benzodiazepine and Anxiolytic Medications undated, revealed to Attempt gradual dose reduction (GDR) as ordered by the physician and according to the following: within the first year, a GDR must be attempted in two separate quarters (with at least one month between attempts, unless otherwise contraindicated, ongoing assessment and… …
F758 citations in Pennsylvania
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
Pennsylvania cites F758 more often than its own record predicts
1.03 times the share F758 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F758 findings written in Pennsylvania, 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 clinical record review and resident and staff interviews, it was determined that the facility failed to show adequate monitoring of symptoms and potential adverse consequences of psychoactive drug use for one resident out of 27 residents sampled (Resident 45). Findings include: A review of clinical records revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Parkinson's (progressive neurological disorder that… …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 1.33% | 0.81× |
| 2024 | 1.39% | 0.94× |
| 2025 | 0.65% | 1.03× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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