Based on review of facility policy, record review and interview, the facility failed to protect Resident (R)1 from being physically restrained by Certified Nursing Assistant (CNA)1. Specifically, CNA1 grabbed both of R1's hands, held them crossed against R1's upper chest during incontinence care, for 1 of 3 residents reviewed. On 03/20/25 at 2:00 PM the Administrator and the Director of Nursing were notified that the failure to protect a resident from being physically restrained constituted IJ at F604. On 03/20/25 at 2:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/02/25. …
F604 citations in South 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
South Carolina cites F604 less often than its own record predicts
0.84 times the national share — cited less often here than elsewhere.
Of every deficiency written in South 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 South Carolina surveyors wrote
F604 findings written in South 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 upon observations, interview, record review, and review of facility policy, the facility failed to ensure that one (1) of one sampled residents reviewed for physical restraints (Resident #1) was free of physical restraint use implemented for staff convenience. Resident #1 was physically restrained by Certified Nursing Assistant (CNA) #1 on 7/18/2020 causing harm to Resident #1. Resident #1 was restrained in bed to prevent her/him from moving; a sheet was tied tightly across the resident's body with the four corners of the sheet affixed to the bed frame. When the resident was found by a nurse, s/he had experienced psychosocial and physical harm including indentations in her legs from the pressure of the sheet. …
Based on observation, interview, record review, and review of the facility policy titled, the facility failed to ensure one of one resident reviewed for unnecessary physical restraints (Resident (R) 12) was free from an unnecessary physical restraint. The resident's individualized Broda chair was switched out with a replacement Broda chair that prevented R12 from independently propelling herself and from using her customary method of locomotion. The facility failed to complete an individualized seating assessment following the equipment change, and continued use of the replacement chair for approximately one week despite R12's inability to independently propel herself. …
The short window
Recent years
| Year | Share of South Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.47% | 1.24× |
| 2024 | 0.48% | 1.32× |
| 2025 | 0.32% | 0.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Carolina surveyors cite →
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