Based on observation, interview, and record review, the facility failed to ensure that four-point restraints (a device used to support impaired posture that restricts a resident's freedom of movement) were applied in a safe manner, and failed to establish the medical need for the restraint, implement assessments, care planning, and supervision that focused on the specific restraint use for 2 of 2 residents (Residents 1 and 5), reviewed for physical restraints. This failed practice placed Resident 1 at serious risk of entrapment, strangulation, and death, and placed both Resident 1 and Resident 5 at risk for a decline in physical function, restriction of free movement, risk of injury, loss of dignity, and was determined to be an immediate jeopardy. …
F604 citations in Washington
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
Washington cites F604 more often than its own record predicts
1.75 times the share F604 takes of citations nationally.
Of every deficiency written in Washington 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 Washington surveyors wrote
F604 findings written in Washington, 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 the facility failed to ensure one of three residents (63) sampled for abuse, remained free from restraint by transfer of the resident to a locked unit that was imposed for purposes of staff convenience. Additionally, the facility failed to comprehensively assess and monitor the need for placement in the facility locked unit and did not disclose to the Power of Attorney the room change was to a locked unit. This failure led to psychosocial harm, which included disorientation to new environment, wanting to get out of the locked unit, and requesting to go back to previous room. …
Based on observation, interview, and record review, the facility failed to complete and/or obtain an assessment, consent, and/or physician's order for 1 of 1 sampled resident (Resident 39) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Physical Restraints, undated, documented . 5. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. 8. Restraints will only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Resident 39 was admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.43% | 1.13× |
| 2024 | 0.43% | 1.16× |
| 2025 | 0.66% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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