Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) was free from the use of physical restraint when staff placed a broom in the spokes and behind R1's wheelchair, restraining her movement. This resulted in actual psychosocial harm when R1 became tearful and agitated over a number of weeks when this practice was in place. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R1 required extensive assist of one staff with activities of daily living (ADL's) which included bed mobility, transfers, and locomotion on and off unit. In addition, MDS identified R1 was noted to wander. The facility report number 5 dated 2/23/21, at 7:39 p.m. …
F604 citations in Minnesota
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
Minnesota cites F604 more often than its own record predicts
1.33 times the share F604 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F604 findings written in Minnesota, 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 assess the use of a wheelchair seatbelt to determine whether the seatbelt restricted the resident's freedom of movement and constituted a physical restraint for 1 of 1 resident (R81) reviewed for physical restraints.Findings included:R81's admission Minimum Data Set (MDS), dated [DATE], identified R81 had severe cognitive impairment and required assistance with activities of daily living (ADLs). R81's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by an injury), vascular dementia with agitation (a decline in thinking and memory caused by reduced blood flow to the brain, accompanied by agitation), and non-Alzheimer's dementia (a decline in memory, thinking, and ability to… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.45% | 1.18× |
| 2024 | 0.67% | 1.83× |
| 2025 | 0.50% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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