Print Violation: 00232348-AP-190151

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 11/16/2022
Report number: 00232348-AP-190151
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to perform adequate screening or assessment
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: 411-054-0036(2)(g)
External site: 411-054-0040(1)(a) and (d)
External site: 411-054-0045(1)(f)(A)
Findings: The facility failed to perform adequate assessments, implement interventions and appropriately care plan related to the Alleged Victim’s (AV) history of falls, several requiring emergency services. On or about October 17, 2022, AV’s service plan noted a change of condition due to increase in falls, though no meaningful interventions were placed to mitigate the risk of falls or injury. On or about November 15, 2022, AV returned from the hospital, after experiencing an unwitnessed fall with injury to his/her head and skin with no changes in instruction. On or about November 16, 2022, AV was found on the floor, following an unwitnessed fall, unresponsive, had sustained a head injury, and passed away. The facility’s failures are a violation of resident rights, are considered neglect of care and constitute abuse.
Sanction: ALFCP23-00210 $2500.00 fine assessed