Based on observations, closed and current clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that least restrictive measures were attempted and were ineffective, prior to implementing physical restraints for residents who exhibited agitation, restlessness and combative behaviors, failed to provide ongoing re-evaluation for the need and safe use of the restraints despite these behaviors, and failed to document the condition of the resident's skin when the restraints were removed and skin breakdown was identified, resulting in Substandard Quality of Care involving six residents (#'s 12, 11, 6, 13, 3 and 9). …
F604 citations in Arizona
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.
Against expectation — 2025
Arizona cites F604 more often than its own record predicts
1.01 times the share F604 takes of citations nationally.
Of every deficiency written in Arizona in 2025, this is the portion that was F604.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Arizona surveyors wrote
F604 findings written in Arizona, 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 observation, record review, interviews, and facility policy review the facility failed to ensure one of thirty-three sampled residents (#36) was free from physical restraint related to bed rails. The universe was one hundred and seventy-eight. The deficient practice could cause a resident to suffer physical injury from entrapment or psychosocial harm related to restraint use. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. …
The short window
Recent years
| Year | Share of Arizona citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 0.45× |
| 2024 | 0.31% | 0.84× |
| 2025 | 0.38% | 1.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Arizona surveyors cite →
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