Based on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to be free from physical restraint (is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). On 1/14/2026 at 3 a.m., Licensed Vocational Nurse (LVN) 1 found the hands of Resident 1, who had severe cognitive impairment (is a profound, often irreversible loss of mental capacity involving a major inability to think, remember, learn, communicate, or make decisions, requiring daily assistance with basic tasks like eating,… …
F604 citations in California
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
California cites F604 more often than its own record predicts
1.25 times the share F604 takes of citations nationally.
Of every deficiency written in California 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 California surveyors wrote
F604 findings written in California, 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, interview, and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. …
Based on observation, interview, and record review, the facility failed to ensure their policy and procedure (P&P) for Restraints or Seclusion was followed for one of two sampled residents (Resident 7) when Resident 7 was not assessed every two hours while using a right-hand mitten (soft mittens placed over a resident's hands to stop them from pulling at medical equipment) restraint. This failure had the potential for Resident 7 to be at risk for severe physical and psychological harm (mental distress), including suffocation (not being able to breathe), nerve and skin damage, blocked blood flow, stiff joints, and extreme distress.During the review of Resident 7 admission Record(clinical record with demographic information), the admission Record indicated Resident 7 was admitted to the… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.46% | 1.20× |
| 2024 | 0.57% | 1.55× |
| 2025 | 0.47% | 1.25× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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