Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00285542-AP-239868
Provider Information
Grove Pointe Senior Living
3110 19TH AVE
Forest Grove, OR 97116
- Provider ID
- 5MA146
- Administrator
- Heinz Gehner
- Phone
- (503) 357-3288
- heinz.gehner@sincerisl.com
Violation Details
- Date
- 9/10/2023
- Report number
- 00285542-AP-239868
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to answer call light in a timely manner
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) failed to answer the Alleged Victim’s (AV) call pendant in a timely manner when the AV was on the commode. On or about September 10, 2023, AP2 placed the AV on the commode at approximately 8:00 pm and responded to a call pendant for the AV around 9:00 pm. At approximately 9:06 pm, the AV used their call pendant to call for assistance and used their personal cell phone to call the facility, but no one responded for approximately one hour and forty minutes. At around 10:40 pm, staff responded to the call light and found the AV on the commode without a pulse. In the commode was an extremely large bowel movement and an excess amount of blood. Emergency services were called immediately but the AV was pronounced deceased at the scene. AP2’s failure to respond to the AV’s call light timely is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility’s failure which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-01089 $2500.00 fine assessed