Based on interview, record review and review of other documentation as indicated, it was determined that for one (R70) out of six residents reviewed for abuse, the facility failed to assure that a physical restraint was used to treat R70's medical symptoms and was not being used for staff convenience. Findings include: R70, a resident with dementia, had two gowns on during the evening shift of 3/31/25. The first gown was on in the correct position. The second gown was oversized and the gown material was gathered and tied in a knot below R70's knees and behind her neck to prevent R70 from exposing herself. …
F604 citations in Delaware
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
Delaware cites F604 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F604 findings written in Delaware, 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 that one of 31 sampled residents (Resident (R) 28) was free from physical restraints when staff failed to identify a seatbelt worn on a motorized wheelchair as a physical restraint, restricting the resident's freedom of movement and access to their body. This failure created the potential for facility residents to receive inappropriate care and services, or a lack of, due to unidentified care needs and interventions from an unassessed lower extremity restraint. Findings include:Review of R28's Face Sheet, located in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2024 | 0.35% | 0.96× |
| 2025 | 0.21% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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