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 citations in Illinois
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
Illinois cites F604 less often than its own record predicts
0.87 times the national share — cited less often here than elsewhere.
Of every deficiency written in Illinois 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 Illinois surveyors wrote
F604 findings written in Illinois, 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 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 observations, interviews and record reviews, the facility failed to prevent the physical restraint of a resident's movement per facility policy.This applies to 2 of 3 residents (R1 and R3) reviewed for falls in a sample of 4.The findings include:1. Face sheet, printed 8/15/26, showed R3's diagnoses included neurocognitive disorder with Lewy bodies, psychotic disorder with delusions, unsteadiness on feet, anxiety, mood affective disorder, cerebrovascular disease, visual hallucinations, difficulty walking, abnormalities of gait and mobility, and muscle wasting and atrophy. Review of R3's care plan showed R3 may be at risk for falls related to weakness and immobility secondary to anxiety disorder, Parkinson's disease, mood disorder, polymyalgarheumatica, and insomnia. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 1.39× |
| 2024 | 0.37% | 1.01× |
| 2025 | 0.33% | 0.87× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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