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F605: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function

F605 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. It sits in CMS's freedom from abuse, neglect, and exploitation category.

1,577citations in the CMS files
1,525homes cited at least once
1,045in the 12 months to September 2026
1.2%rated actual harm or immediate jeopardy

CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.

How seriously inspectors rate it

Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 12.5% of F605 citations came from a complaint visit rather than a routine inspection.

  • Immediate jeopardy (J, K, L)11 (0.7%)
  • Actual harm (G, H, I)8 (0.5%)
  • Potential for more than minimal harm (D, E, F)1,556 (98.7%)
  • Potential for minimal harm (A, B, C)2 (0.1%)

By letter: B 1, C 1, D 1,260, E 293, F 3, G 8, J 11.

What inspectors wrote

Three recent F605 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.

Inspectors wrote, August 13, 2026, scope and severity DBased on interview and record review, the facility failed to ensure a PRN (as-needed) antipsychotic medication was limited to 14 days and that the continued use of the PRN antipsychotic medication was evaluated by the attending physician or prescribing practitioner for 1 of 1 residents (R12) reviewed for unnecessary medications.

St. Anthony Park Home Inc, Saint Paul, MN

Inspectors wrote, August 7, 2026, scope and severity DBased 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.

Belmont Care and Rehabilitation, Portland, OR

Inspectors wrote, August 6, 2026, scope and severity DBased on record review, staff interview, and policy review, the facility failed to ensure 1 of 3 sampled residents on antipsychotic medications had diagnoses to support the justification and use of the medication and the negative side effects it can cause in the elderly (Resident #19). The facility reported a census of 24 residents.

Stacyville Community Nursing Home, Stacyville, IA

Most recent F605 citations at the harm or jeopardy level

Newest first, all 19 in the current files. Each home's page shows the citation in full context, with its correction status.

InspectionHomeTownLetterVisit
July 28, 2026Brookside Care CenterStockton, CA GComplaint
July 8, 2026Arcadia Care WatsekaWatseka, IL GComplaint
June 23, 2026Ark Healthcare & Rehabilitation at St. CamillusStamford, CT JComplaint
April 23, 2026Aliya of CrestwoodCrestwood, IL GStandard
November 23, 2025Marlora Post Acute Rehab HospLong Beach, CA JComplaint
October 30, 2025The Orchards at Three RiversThree Rivers, MI JComplaint
October 9, 2025Jasper County NhBay Springs, MS GStandard
October 1, 2025Corewell Health Rehabilitation & Nursing Center -Stevensville, MI JComplaint
August 19, 2025Lancaster Health ServicesLancaster, WI JStandard
May 22, 2025Duquoin Nursing & RehabDu Quoin, IL GComplaint
May 9, 2025Northgate Health and Rehabilitation CenterBessemer, AL JComplaint
April 3, 2025St. Vincent's - a Prospera CommunityBismarck, ND GComplaint
April 3, 2025New York State Veterans Home at MontroseMontrose, NY GComplaint
February 10, 2025The Gables of Pelham Skilled Nursing & RehabGreenville, SC JComplaint
December 20, 2024Axiom Healthcare of West FrankfortWest Frankfort, IL JComplaint
June 21, 2024Pruitthealth- DillonDillon, SC JStandard
May 28, 2024Peterson Rehabilitation and HealthcareWheeling, WV JComplaint
November 20, 2023North Village ParkMoberly, MO JComplaint
November 9, 2018Idaho State Veterans Home - BoiseBoise, ID GStandard

Most recent F605 citations

InspectionHomeTownLetter
August 13, 2026St. Anthony Park Home IncSaint Paul, MN D
August 7, 2026Belmont Care and RehabilitationPortland, OR D
August 6, 2026Stacyville Community Nursing HomeStacyville, IA D
August 5, 2026Edwardsville Care and RehabEdwardsville, KS D
July 31, 2026South Coast Post AcuteSanta Ana, CA D
July 30, 2026Mesa Hills Post AcuteBrownsville, TX D
July 30, 2026Mt Macrina ManorUniontown, PA D
July 30, 2026Life Care Center of FarmingtonFarmington, NM E
July 30, 2026Kittson HealthcareHallock, MN D
July 30, 2026Ocean Grove Post AcuteMillsboro, DE D
July 29, 2026Marshall Manor Nursing & Rehabilitation CenterMarshall, TX D
July 29, 2026Aventura at PembrookeWest Chester, PA E
July 28, 2026Weslaco Nursing and Rehabilitation CenterWeslaco, TX D
July 28, 2026Westy Community Care HomeWestmoreland, KS D
July 28, 2026Brookside Care CenterStockton, CA G
July 24, 2026The Lev at San AntonioSan Antonio, TX E
July 24, 2026Abington ManorClarks Summit, PA D
July 24, 2026Sweden Valley ManorCoudersport, PA D
July 24, 2026The Gardens at Winsted LLCWinsted, MN D
July 24, 2026Franklin County Transitional CarePreston, ID D
July 23, 2026Mountain Laurel Healthcare and Rehabilitation CtrClearfield, PA E
July 23, 2026Lutheran HomeNapoleon, OH D
July 23, 2026Sanford Health & Rehabilitation CoSanford, NC D
July 23, 2026Shirley Chapman Sholom Home EastSaint Paul, MN D
July 23, 2026Grand Park Convalescent HospitalLos Angeles, CA E

F605 citations by state

Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.

StateCitations
California323
Pennsylvania132
Ohio83
Illinois78
Minnesota73
Texas67
Washington66
Kansas65
Indiana54
Iowa45
Michigan45
Nebraska41
Wisconsin41
Louisiana35
Missouri35
Maryland33
Colorado26
Massachusetts26
Oklahoma25
New Jersey24
Oregon24
New Mexico22
North Carolina17
Utah16
Georgia15
New York15
Mississippi14
Maine10
Montana10
Virginia10
Wyoming10
Florida8
New Hampshire8
West Virginia8
Idaho7
Delaware6
North Dakota6
Arkansas5
Arizona5
Rhode Island5
South Carolina5
South Dakota5
Vermont5
Nevada4
Tennessee4
Alabama3
Kentucky3
Puerto Rico3
Connecticut2
Guam2
Hawaii2
Alaska1

By inspection year: 2018 1, 2019 2, 2021 1, 2022 1, 2023 7, 2024 25, 2025 763, 2026 777.

Common questions

What is F605 in a nursing home inspection?
F605 is the federal requirement to "prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function". CMS files it under freedom from abuse, neglect, and exploitation. A home cited under F605 did not meet that requirement at the inspection.
How often is F605 cited?
The CMS files as of September 1, 2026 list 1,577 F605 citations at 1,525 nursing homes, 1,045 of them in the 12 months to that date. 1.2% were rated as actual harm or immediate jeopardy.
Is a F605 citation serious?
It depends on the letter. Most F605 citations (98.7%) were rated as potential for more than minimal harm, D to F. 11 were immediate jeopardy, the most serious level.

The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology

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