Print Violation: 00412390-AP-429313

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 7/7/2025
Report number: 00412390-AP-429313
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
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) is full assist with mobility and transfers. During the time frame of May 13, 2025, through July 7, 2025, AV suffered eleven falls, with four of those falls resulting in injury. On or about June 16, 2025, AV suffered a fall that resulted in a closed fracture to his/her left arm. Between May 13, 2025, and July 3, 2025, only two new interventions were put into place to reduce falls, which were not effective in reducing falls. Respondent failed to ensure interventions were in place to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: ALFCP26-00293 $1500.00 fine assessed