Print Violation: 00402538-AP-353445

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 5/16/2025
Report number: 00402538-AP-353445
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate 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)
411-054-0030(1)(e)(G)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) was care planned for 2 hour checks to check and change his/her brief and to empty AV's catheter. Staff were not regularly providing personal cares or emptying AV's catheter. From approximately May 16, 2025, to May 19, 2025, AV's brief was not changed by staff and on May 19, 2025, AV was found to be soaked as his/her catheter was leaking and AV's skin was very red, causing unreasonable discomfort. Respondent failed to ensure staff followed the service plan to change AV's brief, causing unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: ALFCP26-00243 $188.00 fine assessed