Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure that one (1) of twenty-two (22) sampled residents (Resident #1) remained free from physical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Interviews conducted with Resident #1, five (5) State Registered Nursing Assistants (SRNAs), two (2) Licensed Practical Nurses (LPNs), and the Director of Nursing (DON) all revealed that Resident #1 was being placed in a reclining Geri-chair, which he/she could not voluntarily get out of, to facilitate staff getting their work done, retaliation for sustaining falls, using the call light excessively, requesting to use the bathroom, and as punishment for not being… …
F604 citations in Kentucky
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
Kentucky cites F604 less often than its own record predicts
0.73 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F604 findings written in Kentucky, 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, record review, and review of facility Policy, it was determined the facility failed to ensure alternatives were attempted prior to use of a restraint; failed to ensure the restraint was used for the least amount of time; failed to have a systematic process for reduction of the restraint; and failed to implement interventions to prevent risks associated with the restraint for one (1) of two (2) sampled residents reviewed for restraints out of a total of twenty-eight (28) sampled residents (Resident #88). …
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from physical restraints, failed to have documented evidence of assessments for the restraints, and failed to document ongoing re-evaluation of the need for the restraints when the use of restraints was indicated, for 3 of 3 sampled residents, Resident (R) 10, R38, and R41. Observations of R10, R38, and R41 on 05/26/2026 and 05/27/2026 revealed the residents sitting in their motorized wheelchairs with a restraint device on the residents.The findings include:Review of the facility's policy titled, Use of Restraints, revised December 2007, revealed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives… …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 0.62% | 1.61× |
| 2025 | 0.28% | 0.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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