Print Violation: 00132012-AP-103335

Provider Information

Klamath Falls Senior Living

2130 N ELDORADO AVE
Klamath Falls, OR 97601

Date: 3/29/2021
Report number: 00132012-AP-103335
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide oversight and monitoring of change of condition
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0040(1)(b)
External site: 411-054-0045(1)(f)
Findings: Between March 21 and March 23, 2022, AV experienced a change of condition that included approximately three falls and high blood pressure readings. AP2 was notified and asked to assess AV according to OAR 411-054-0040(1)(b). AP2 failed to assess or appropriately respond to AV's change of condition according to OAR 411-054-0045(1)(f) or document any contact with AV's primary care physician. The facility failed to oversee staff and ensure that staff followed the applicable regulations and provided appropriate care. Failure to timely respond to, assess, and follow-up on treatment related to AV's change of condition constituted a failure to provide basic care and services as required by rule, resulting in a risk of harm to the resident as well as harm to the resident in experiencing unreasonable discomfort. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: ALFCP22-00982 $188.00 fine assessed