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F0657
D

Failure to Timely Update Care Plan After Resident Aggression

Creswell, Oregon Survey Completed on 12-11-2025

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 update the care plan for a resident with dementia following a reported incident of agitation and subsequent physical aggression. The resident was admitted with a diagnosis of dementia and was involved in an incident where the care plan was supposed to be revised to include an intervention to keep the resident further than an arm's length away from others when agitated. Although this intervention was identified after a facility reported incident, the care plan was not updated until after a second incident of physical aggression occurred. The Director of Nursing Services acknowledged that the care plan should have been updated within five days of the initial incident but was not revised in a timely manner.

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