Print Violation: 00445970-AP-398014

Provider Information

Pelican Pointe

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 12/14/2025
Report number: 00445970-AP-398014
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-05-0027(1)(g) and (s)
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) suffered 8 falls within 30 days, suffering bruises, skin tears, hitting his/her head and unreasonable discomfort. AV was not care planned as a fall risk. AV was prescribed a wheelchair by his/her physician, however, it doesn't appear, according to documentation, that it was being utilized. The facility had not implemented meaningful interventions to reduce AV's risk for falls. Respondent failed to ensure staff implemented interventions to reduce AV's risk of falling. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00300 $500.00 fine assessed