Based on staff interview, facility document review, and clinical record review, the facility staff failed to keep the resident from being physically restrained while obtaining a urine sample that resulted in hospitalization, thus resulting in the determination of Immediate Jeopardy (IJ) for one of 36 residents in the survey sample, Resident #42, (R42). After IJ was removed, the scope and severity was lowered to a level 3 (three), isolated, harm. The findings include: For Resident #42 (R42), the facility staff failed to protect the resident from being physically restrained while obtaining a urine sample which resulted in IJ and harm. R42 was admitted to the facility with diagnosis that included but was not limited to benign prostatic hyperplasia (1). …
F604 citations in Virginia
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 — 2023
Virginia cites F604 less often than its own record predicts
0.17 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2023, 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 Virginia surveyors wrote
F604 findings written in Virginia, 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 staff interviews, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure one Resident, Resident #1, of three residents in the survey sample was free from application of physical restraints. This resulted in psychosocial harm for Resident #1. The findings included: For Resident #1, the facility staff failed to prevent a CNA (Certified Nursing Assistant) from restraining Resident #1 in a wheelchair. Resident #1, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/18/2019 was coded as an entry assessment. …
Based on observation, interview and clinical record review the facility failed to ensure a resident's right to be free from physical restraint for one resident (R1) in a survey sample of ten residents.For R1 the facility staff did not ensure proper the resident had the proper assessment and re-evaluations for continued use of restraints.R1 was admitted to the facility on [DATE] with diagnoses that include but were not limited to dysphagia post stroke, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, gastro esophageal reflux disease. …
What else Virginia surveyors cite →
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