Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to provide an environment free from the use of physical restraint used for staff convenience, that unnecessarily inhibited a resident's freedom of movement or activity for 1 of 1 (Resident #1) sampled residents reviewed for restraints. On 8/18/2024, a phlebotomist from an outside agency contracted with the facility and Resident #1's private sitter physically restrained Resident #1, while he yelled No during an attempt to obtain blood. The phlebotomist notified Licensed Practical Nurse (LPN) G that she was unable to obtain the blood, and LPN G entered Resident #1's room and observed Resident #1's private sitter holding his arms down across his body. …
F604 citations in Tennessee
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
Tennessee cites F604 more often than its own record predicts
1.51 times the share F604 takes of citations nationally.
Of every deficiency written in Tennessee 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 Tennessee surveyors wrote
F604 findings written in Tennessee, 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 facility policy review, medical record review, observations, and interviews, the facility failed to perform an assessment for the use of a seatbelt for 2 residents (Resident #34 and #67) of 3 residents reviewed for physical restraints.The findings include: Review of the facility's policy dated 4/2017 titled Use of Restraints, revealed .individuals shall be reviewed regularly (at least quarterly) . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Type II Diabetes. …
The short window
Recent years
| Year | Share of Tennessee citations | vs expected |
|---|---|---|
| 2023 | 0.66% | 1.72× |
| 2024 | 0.73% | 2.00× |
| 2025 | 0.58% | 1.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Tennessee surveyors cite →
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