Based on interviews, and record review it was determined the facility failed to protect the resident's right to be free from physical restraints for 1 of 3 sampled residents (# 12) reviewed for abuse. This failure resulted in Resident 12 experiencing psychosocial harm with suicidal ideation, increased depression symptoms, heightened anxiety, and fear of losing her/his home. Findings include: Resident 12 was admitted to the facility in 2015 with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso), contractures of the right and left hand, right elbow, and lower extremities (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the body part), and a history of traumatic brain injury. …
F604 citations in Oregon
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
Oregon cites F604 less often than its own record predicts
0.83 times the national share — cited less often here than elsewhere.
Of every deficiency written in Oregon 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 Oregon surveyors wrote
F604 findings written in Oregon, 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 it was determined the facility failed to complete an accurate assessment prior to initiating restraint use and did not conduct ongoing assessments for 1 of 1 sampled residents (#50) reviewed for restraints. This placed residents at risk for unnecessary restraint use and reduced self-mobility. Findings include: The facility's 4/2017 Use of Restraints policy listed examples of restraints, which included a Geri-chair (medical chair that is a combination of a wheelchair and recliner chair). The policy instructed the facility:- restraints were only to be used when a resident's specific medical condition that could not be addressed by another less restrictive intervention and a restraint is required to a. treat the medical condition; b. …
The short window
Recent years
| Year | Share of Oregon citations | vs expected |
|---|---|---|
| 2023 | 0.23% | 0.61× |
| 2024 | 0.38% | 1.03× |
| 2025 | 0.31% | 0.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Oregon surveyors cite →
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