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F0610
D

Failure to Thoroughly Investigate Abuse Allegation

Woodburn, Oregon Survey Completed on 12-12-2025

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

The facility failed to thoroughly investigate an allegation of abuse involving a resident with dementia and agitation who had a care plan indicating a history of verbal and physical behaviors toward staff, requiring care to be provided in pairs. On the date of the incident, a CNA was physically struck multiple times by the resident during care. Shortly after, the resident admitted to hitting and kicking the CNA but also alleged that the CNA had abused them first. The LPN on duty notified facility management of the abuse allegation. The facility's investigation into the incident was incomplete, lacking staff witness statements, investigation notes, and a summary of the incident. Both the Director of Nursing Services and the Regional Director of Clinical later confirmed that the investigation was not thorough or complete. The documentation did not provide sufficient detail or evidence to demonstrate that the allegation of abuse was appropriately investigated.

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