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F0550
D

Failure to Ensure Resident Dignity and Respect During Care

Eugene, Oregon Survey Completed on 06-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident, admitted with anxiety and cognitively intact, was not treated with dignity and respect by a CNA. The resident required moderate assistance for transfers and toileting and had interventions in place for anxiety, including one-on-one support. On the evening or night shift, the resident requested a female CNA for assistance with a shower, but was told by the male CNA that none was available and was met with an inappropriate comment. During toileting and transfer assistance, the CNA reportedly used profane language, handled the resident roughly by grabbing and tossing their legs onto the bed, and threw the resident's walker into the corner. The resident reported feeling frightened and cried during the incident, while the CNA continued to use inappropriate language and displayed aggressive behavior. Multiple grievances were filed against the CNA by residents, and staff interviews confirmed that the CNA was perceived as gruff and rough around the edges. The CNA admitted to possibly using profanity and moving equipment roughly, though he denied intentional harm. The facility's Director of Nursing and Regional RN Consultant stated that they ruled out abuse and neglect, citing inconsistencies in the resident's account, but the incident was substantiated through resident and staff interviews and the facility's investigation.

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