Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00286423-AP-240654
Provider Information
Klamath Falls Senior Living
2130 N ELDORADO AVE
Klamath Falls, OR 97601
- Provider ID
- 70M024
- Administrator
- Eileen McCoy
- Phone
- (541) 882-4830
- ed.klamathfalls@klamathfallsseniorliving.com
Violation Details
- Date
- 6/6/2023
- Report number
- 00286423-AP-240654
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- 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) and (c)
External site: 411-054-0045(1)(f)
- Findings
- AV has a medical condition which requires weekly skin checks and has a history of being non-compliant with receiving facility care. Both the skin checks and non-compliance with care were addressed in AV’s service plan. The facility failed to ensure that the service plan was followed because weekly skin checks were not performed. The facility also failed to appropriately care plan according to AV’s needs and behaviors and provide staff with instructions regarding monitoring and the delivery of services with respect to non-compliance with care because the interventions were limited and not effective. On or about June 4, 2023, staff became aware of AV’s significant change of condition and reported their findings to AP2 that day, and the worsening of his/her condition the following day. However, AP2 failed to properly assess AV's change of condition, provide sufficient instruction on interventions or monitoring, and failed to follow up on AV’s condition according to OAR 411-054-0045(1)(f). On or about June 6, 2023, AV went to his/her doctor related to the significant change of condition and was sent to the hospital, where his/her leg was amputated approximately three (3) days later. The failure of the facility and AP2 to provide basic care and services necessary to maintain the health of safety of AV resulted in permanent loss to AV, which constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP24-00668 $2500.00 fine assessed