Print Violation: 00092606-AP-069807

Provider Information

Heron Pointe Senior Living

504 Gwinn Street East
Monmouth, OR 97361

Date: 7/11/2020
Report number: 00092606-AP-069807
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0040(1)(a) and (d)
Findings: The facility failed to appropriately care plan for Alleged Victim's (AV) high fall risk. On July 11, 2020, AV fell and was diagnosed with a fractured humerus. On July 13, 2020, the facility noted a Significant Change of Condition for AV due to falls, specifically stating that AV needed increased assistance and supervision with his/her Activities of Daily Living (ADL). However, AV fell twice more in his/her room on July 15, 2020. An investigation determined that AV suffered six falls between June 29, 2020 and July 2, 2020. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP21-01160 $375.00 fine assessed