Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident with known recurrent behaviors was not restrained to keep him from getting up from his room recliner for 1 of 1 randomly observed residents. (Resident 41) The Immediate Jeopardy began on 7/21/2021 when the facility failed to ensure Resident 41 was not restrained from rising from his room recliner and leaving his room. The Administrator was notified of the Immediate Jeopardy at 2:35 P.M. on 7/23/2021. …
F604 citations in Indiana
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
Indiana cites F604 less often than its own record predicts
0.59 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F604 findings written in Indiana, 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 a consent with the identified medical reason for the use of a restraint was completed at the initiation of the restraint, to establish a time frame for continuing the use of the restraint and to establish how the restraint would be decreased and discontinued for 1 of 1 resident reviewed for restraints. (Resident 70) This deficient practice resulted in Resident C having three (3) falls with major injuries while using the restraint, had 3 emergency room evaluations and was diagnosed with nasal fractures, lacerations to her face which required sutures, and a laceration to her upper lip which required sutures. …
Based on observation, interview, and record review, the facility failed to ensure the resident was assessed and a physician order was obtained prior to utilizing an audible bed and chair alarm for 1 of 2 residents reviewed for falls (Resident B). Findings include:On 6/17/26 at 12:35 p.m. during an initial observation and interview, Resident B sat in the main dining room with her husband. She was alert with some confusion noted during the interview. The resident indicated she had some falls but had not been hurt any of the times she fell. The resident was sitting in her wheelchair on a black air filled cushion and an incontinent pad. No anti-skid material was observed in the wheelchair. Observed anti-tip bars to the lower bottom of the wheelchair. The bars were upside down. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.15% | 0.39× |
| 2024 | 0.26% | 0.71× |
| 2025 | 0.22% | 0.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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