Print Violation: 00356039-AP-323351

Provider Information

Heron Pointe Senior Living

504 Gwinn Street East
Monmouth, OR 97361

Date: 6/6/2024
Report number: 00356039-AP-323351
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
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(1)(a) and (b)
External site: 411-054-0030(e)(A)
Findings: Alleged Victim (AV) requires 2-3 person assist for transfers. staff are trained on transfers. AV has complained repeatedly about staff being too aggressive with the gait belt, which has resulted in AV being afraid of staff using the gait belt. AV has been pinched by the gait belt leaving red marks on multiple occasions. On June 6, 2024, AV was being helped into the shower when a bruise was noticed on the left side of AV's chest. AV reported that the bruise was caused by staff using a gait belt while transferring AV. The incident reports states that AV had mild pain from the bruise. AV reports the gait belt caused severe pain. The Unknown Alleged Perpetrator #6 was transferring AV with the gait belt, admitted that it was the gait belt that bruised AV. The incident report and staff do not remember the name of AP6. The facility failed to provide a safe environment, which is a violation or resident rights, is considered neglect of care and constitutes abuse. An investigation inconclusively determined AP2 abused and neglected AV.
Sanction: ALFCP25-00374 $250.00 fine assessed