Print Violation: 00373343-AP-323749

Provider Information

Klamath Falls Senior Living

2130 N ELDORADO AVE
Klamath Falls, OR 97601

Date: 12/19/2024
Report number: 00373343-AP-323749
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) relied on the facility for care, was a fall risk due to poor judgement and prior fall history, was care planned for four (4) safety checks per shift and also was documented as independent with short distance ambulation and transfers. According to an investigation, facility staff were not checking on AV frequently because AV was independent. In October 2024, after a previous fall, AV's physician had ordered physical and occupational therapy but there is no documentation this occurred. On or about December 19, 2024, AV was found on the floor next to the head of AV's bed with AV's back to the wall and did not respond when staff asked what happened. AV was sent to the hospital approximately three (3) days later, on December 22, 2024, and was diagnosed with a left hip fracture that required surgical intervention. The facility failed to provide appropriate services according to AV’s needs, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP26-00208 $1500.00 fine assessed