Based on interview and record review, the facility failed to ensure a resident, who had diagnoses of congestive heart failure ([CHF] a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease with acute exacerbation ([COPD] a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a long-term condition where the lungs cannot supply enough oxygen to the blood or remove enough carbon dioxide) and dependence on supplemental oxygen (O2) was not administered a narcotic (a substance used to treat moderate to severe pain by binding to opioid receptors in the central nervous system)-analgesic (a drug or agent used to relieve pain, acting as a painkiller);… …
F605 citations in California
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.
Against expectation — 2025
California cites F605 more often than its own record predicts
1.26 times the share F605 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F605.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F605 findings written in California, 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 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… …
Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic (prescription drugs that change how the brain works to affect mood, thoughts, feelings, and behaviors) medications when the facility did not attempt or implement non-pharmacological intervention (any treatment, therapy, lifestyle change, or environmental adaptation used to prevent, manage, or treat health conditions without the use of medication) monitoring for residents on psychotropic medications and failed to carry out a physician ordered antipsychotic(medications used to treat a mental defect) dose reduction as written for four of 18 sampled residents (Resident 20, Resident 6, Resident 7 and Resident 5) when: 1. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.01% | 1.17× |
| 2024 | 0.01% | 0.56× |
| 2025 | 0.89% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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