Deficiency Index

F605

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations in 2025763

Every F605 citation surveyors wrote nationally that year.

Facilities cited754

Distinct nursing homes with at least one F605 finding.

The harm level

How severely F605 is cited

1.2% of citations found actual harm or worse (level G and above).

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ110.7%K—L—
Actual harmG80.5%H—I—
No harm, potential for more than minimalD1,26379.9%E29318.5%F30.2%
No harm, potential for minimalA—B10.1%C10.1%
Every recorded F605 citation, by the harm level and scope the surveyor assigned.

In the surveyor’s words

What an F605 citation says

One finding from each severity level, most serious first.

Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.

J · Immediate jeopardy, isolatedAugust 28, 2026

Based on interview and record review the facility failed to ensure a resident was free from the use of unnecessary psychotropic medications, including polypharmacy for 1 of 3 residents (R1) reviewed for chemical restraints in a sample of 8. This failure caused R1 to develop extrapyramidal symptoms (involuntary movements) and lethargy which contributed to a severe weight loss, the development of pressure ulcers, and overall decline in health. R1 was hospitalized on [DATE] and admitted to the Intensive Care Unit with diagnoses of Septic Shock, Dehydration, Hypernatremia, Transaminitis, Hypoxia, Elevated Troponin, Failure to Thrive, Acute Kidney Injury, Elevated Lactic Acid, Elevated Brain Natriuretic Peptide (BNP), Acute Respiratory Failure, and Multi-Organ Failure. …

Axiom Healthcare of Mount Vernon · Illinois

G · Actual harm, isolatedJuly 28, 2026

Based on interview and record review, the facility failed to ensure that one of three resident's (Resident 1) drug regimen (a detailed plan for taking medication) was free from unnecessary drugs, failed to obtain informed consent (ICO -process where a doctor explains a mind-altering medication, its risks, and benefits, alternatives, ensuring the patient or legal guardian agrees freely before treatment) for the use psychotropic medication (mind altering drugs) prior to Resident 1 starting the medications, failed to monitor for adverse side effects (ASE -harmful, negative, unintended reactions caused by medication treatment) of multiple psychotropic medications with black box warnings (BBW -life threatening risks), and failed to assess, intervene, and transfer Resident 1 to an acute care… …

Brookside Care Center · California

D · No harm, potential for more than minimal, isolatedSeptember 16, 2026

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of a psychotropic medications was documented for 1 of 5 residents (R16) reviewed for unnecessary medication and were taking psychotropic medications. Findings include:R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively intact and had diagnoses that included Alzheimer's disease, dementia, anxiety, restless leg syndrome and type 2 diabetes. R16 used antianxiety medications.R16's Psychotropic Drug Use Care Area Assessment (CAA) dated 8/27/26, identified R16 used Ativan (lorazepam) (an antianxiety medication) daily for anxiety. R16 had recently graduated from hospice and had anxiety regarding end of life. …

North Star Manor · Minnesota

C · No harm, potential for minimal, widespreadJune 8, 2026

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview; the facility failed to complete gradual dose reductions or have documented contraindications for antipsychotic medications for Residents 3 and 4. The sample size was 5 and the facility census was 45. Findings are:A. Review of the facility policy Use of Psychotropic Medication(s) with a revision date of 4/21/25 revealed the following: -the facility ensured residents only receive psychotropic medications when other nonpharmacological interventions were clinically contraindicated. …

Accura Healthcare of O'Neill · Nebraska

By state — 2025

Where F605 is cited more, and less, than expected

Each state is measured against its own expected share, not against other states.

Magenta is cited more often than expected, blue less often.

Co-occurrence

Cited alongside F605

Of the 2025 surveys that cited F605, these tags appeared in the same inspection more often than chance would predict.

Cited in the same inspection, not caused by one another.

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