F755 — Pharmacy Services / Procedures
Failure to provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement, and to maintain accurate records, controlled drug records, and proper storage.
Reg cite · 42 CFR 483.45(a)
84 surveys in corpus
25 states
What surveyors look for
- Drug storage at correct temperatures, with daily logs
- Controlled substance counts at every shift change, with discrepancies investigated within 24 hours
- Expired medications removed from all stations and emergency kits
- Multi-dose vials labeled with open date, discarded per facility policy
Common gotchas
- Med room refrigerator without temperature log or out of range
- Controlled-substance count sheet with same handwriting/initials across multiple shifts
- Floor stock missing or unaccounted for
- Insulin pens not labeled with resident name + open date
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on an interview, review of the facility's Non-Controlled Medication Destruction Records, and review
of a facility policy titled, Non-Controlled Medication Destruction, the facility failed to ensure destruction
dates and required signatures were on the non-controlled medication destruction sheets.
This deficient practice affected non-controlled medication destruction sheets reviewe…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On [date] at 5:16 PM, an unsuccessful telephone attempt was made to contact the Consultant
Pharmacist.
On [date] at 5:18 PM, the Director of Nursing (DON) verified the Record of Medication Destruction
Non-Controlled Drugs sheets with the missing signatures and dates. When interviewed, the DON was
asked how many signatures were required for non-controlled medication destruction sheets. The DON said
two, the pharmacist and a nurse.
40
19
015027
[date]
Department of Health & Human Services
Centers for Medicare & …
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on
record review and interview, the facility's pharmacy services failed to ensure medication administration
orders were accurate to meet resident needs for 2 residents (#'s 29 and 53), out of 18 sampled residents.
This failed practice, of potentially having medications administered incorrectly, placed the resi…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
route, via J-tube, was indicated on the orders, the SOM stated that they were written to be administered
orally, and they were working on correcting the orders. When asked to review Resident's medication
orders to confirm if the resident's medications should be crushed, the SOM stated there was not an order
comment indicating the medications could be crushed. Review of the facility provided policy Denali Center -
Medication Administration, effective date [date], revealed: . Before administering a medication, the…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications
were available for use one resident (#28). The deficient practice could result in resident not receiving
necessary medications ordered by the physician.
Findings include:
Resident was admitted …
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
Related F-tags
Just got cited at F755? Draft your POC in minutes.
Upload your 2567, choose your state, and get a CMS-compliant POC draft you can edit and submit.
Start the drafter →