Based on interview and record review it was determined the facility failed to ensure behavior monitoring was in place related to the use of antipsychotic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary medications. Findings include:Resident 8 was admitted to the facility on [DATE] with diagnoses including depression and delusional disorders.A 3/27/26 physician order revealed Resident 8 was prescribed Olanzapine 5 MG (an antipsychotic medication) once daily for delusions.A review of Resident 8's 7/2026 MAR and 5/2026 care plan revealed no identification or monitoring of targeted behaviors related to antipsychotic use. …
F605 citations in Oregon
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
Oregon cites F605 more often than its own record predicts
1.94 times the share F605 takes of citations nationally.
Of every deficiency written in Oregon 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 Oregon surveyors wrote
F605 findings written in Oregon, 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 Oregon surveyors cite →
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