Based on observation, interview, and record review, the facility failed to ensure a resident (R1) was free from physical restraints applied for staff convenience; failed to assess for the use of physical restraints; failed to identify the specific medical symptoms justifying the use of a physical restraint; failed to notify the resident's representative; and failed to obtain a physician's order for physical restraints for one (R1) of three residents reviewed for restraints in the sample of 20. These failures put R1 at risk for psychosocial impact that includes but is not limited to emotional harm, dehumanization, pain, loss of dignity, self-respect, feeling of imprisonment, increased agitation and restlessness and at risk for serious physical injury. …
F604 · Restraints
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F604 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F604 finding.
The harm level
How severely F604 is cited
6.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J352.1% | K150.9% | L10.1% |
| Actual harm | G482.9% | H— | I— |
| No harm, potential for more than minimal | D1,32381.1% | E20512.6% | F40.2% |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F604 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.
Based on interview and record review, the facility failed to prevent a resident with increased confusion and identified as a high fall risk from being physically restrained. This failure resulted in the resident being barricaded in her bed surrounded by dressers.This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:R1's face sheet showed multiple diagnoses that included unspecified fall, subsequent encounter, other abnormalities of gait and mobility, weakness, tremor, cognitive communication deficit, unspecified psychosis, bipolar disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, recurrent severe without psychotic features, abnormal… …
Based on review of facility policies, clinical records, facility documents, and staff interviews it was determined that the facility failed to identify a perimeter mattress (a specialized mattress that incorporates built-in edge support to create a raised, cushioned, or air-filled rail round the perimeter of the bed) as a possible restraint, failed to identify a pommel cushion (a wheelchair seat cushion with a raised center used to prevent forward sliding) and failed to assess the functional status of the individual resident to determine if the use of a perimeter mattress and pommel cushion is a restraint for one of four residents (Resident R13).Findings include: Review of facility policy Restraints dated 7/1/26, indicated physical restraints are defined as any manual method or physical or… …
Cedar Hill Healthcare and Rehabilitation Center · Pennsylvania
Based on observation, interview and record review, the facility failed to follow their restraint policy for one resident (#105) out of one resident reviewed for restraints resulting in a loss of freedom of movement. Findings include: Resident #105 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 06/06/18 at 11:31 AM, Resident #105 was observed in bed with tube feeding running. Resident #105's wife and son were at the bedside. Resident # 105's wife signed the consent for a full lap restraint. No care plan documentation re: restraint - when to put it on or take it off, etc. …
By state — 2025
Where F604 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Massachusetts2.64× · 26 citations
- California1.25× · 75 citations
- Pennsylvania1.07× · 27 citations
- Texas0.90× · 33 citations
Co-occurrence
Cited alongside F604
Of the 2025 surveys that cited F604, these tags appeared in the same inspection more often than chance would predict.
- F7009.0% of F604 surveys · 5.6× chance
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- F75812.1% of F604 surveys · 4.6× chance
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- F55210.0% of F604 surveys · 4.4× chance
Ensure that residents are fully informed and understand their health status, care and treatments.
- F68812.6% of F604 surveys · 3.8× chance
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- F6459.0% of F604 surveys · 3.6× chance
PASARR screening for Mental disorders or Intellectual Disabilities
Cited in the same inspection, not caused by one another.
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