Print Violation: 00139486-AP-109780

Provider Information

Heron Pointe Senior Living

504 Gwinn Street East
Monmouth, OR 97361

Date: 5/1/2021
Report number: 00139486-AP-109780
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On or about May 1, 201, AV pressed his/her call light and when staff did not respond, AV self-transferred. AV tripped on his/her nighttime catheter bag and fell out of bed and as a result, AV’s ankle was swollen. On this day, Alleged Perpetrator 2 (AP2), did not followed the service plan because AV’s nighttime bag was not changed/replaced with his/her daytime catheter bag. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which if a violation of Oregon Administrative Rules.