Print Violation: 00444851-AP-396867

Provider Information

Pelican Pointe Assisted Living Community

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 12/10/2025
Report number: 00444851-AP-396867
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide inservice
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)
External site: 411-054-0070(1)(b)
Findings: The Alleged Victim (AV) was independent in all care needs prior to November 2025 when he/she was hospitalized due to a fall. AV returned from the hospital on hospice services and his/her care was changed to a two person transfer for assistance and toileting. On or about December 10, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with toileting and left AV alone, assuming that AV's spouse was watching AV. AV fell and hit his/her face, causing swelling and bruising. AV's service plan did not indicate that staff could not leave AV alone. Respondent failed to ensure staff followed the service plan and ensure that staff were properly trained prior to providing care to residents. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction: ALFCP26-00059 $250.00 fine assessed