Based on record review, photographic evidence review, and staff, Law Enforcement Officer, Wound Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a vulnerable resident's right to be free from physical restraints when Resident #1 was found with socks placed on each hand and held in place by rubber bands wrapped around each wrist for 1 of 3 residents reviewed for restraints (Resident #1). On 01/27/25 at approximately 12:00 AM, Resident #1 was observed with socks covering each hand that were secured with rubber bands wrapped around each wrist, effectively forming tourniquets (device often used in emergency situations to apply pressure to a limb or extremity to stop blood flow) on her wrists, but not in a controlled manner. …
F604 citations in North Carolina
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
North Carolina cites F604 less often than its own record predicts
0.51 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F604 findings written in North Carolina, 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 observations, record review, staff and Nurse Practitioner interviews, the facility failed to ensure two cognitively impaired residents were free from the use of physical restraints. A staff member applied gait belts around the residents' abdomen and secured the belts to the back frames of their wheelchairs, restricting their freedom of movement and preventing them from independently rising from the chairs. The residents were unable to remove the belts on their own. There was no physician's order, assessment, care plan or clinical justification for restraint use. This deficient practice occurred for 2 of 2 residents (Resident #3 and Resident #95) reviewed for restraint use. …
Based on observations, record review and interviews with the Nurse Practitioner and staff, the facility failed to assess the use of an abdominal binder (a wide compression belt worn around the abdomen) as a restraint and failed to obtain Responsible Party (RP) written consent for the use of a restraint. This deficient practice affected 1 of 1 resident reviewed for restraints (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety disorder, and metabolic encephalopathy.A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had severe cognitive impairment, no documented behavior, and he was dependent on staff for feeding. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.10% | 0.25× |
| 2024 | 0.28% | 0.76× |
| 2025 | 0.19% | 0.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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