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. …
F605 citations in Minnesota
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
Minnesota cites F605 more often than its own record predicts
1.60 times the share F605 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F605 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.
What else Minnesota surveyors cite →
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