Print Violation: 00429038-AP-380755

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 9/5/2025
Report number: 00429038-AP-380755
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk and has suffered multiple falls between July 29, 2025, and September 14, 2025. Although AV wasn't injured in these falls, AV was placed at risk for harm. AV was care planned to receive checks every two hours, including hygiene and person care during those checks. AV's care plan was not updated to have new interventions for falls until AV's most recent falls in September. The respondent failed to implement meaningful interventions to reduce AV's falls, placing AV at risk for serious harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: ALFCP26-00093 $500.00 fine assessed