Print Violation: 00454615-AP-406739

Provider Information

Pelican Pointe

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 12/27/2025
Report number: 00454615-AP-406739
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: 411-054-0030(1)(e)(A)
External site: 411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk and has suffered multiple falls over a few months. On or about December 27, 2025, AV suffered a fall out of his/her bed and sustained a skin tear and a bruise. AV was on two hour safety checks and was prescribed a wheelchair to assist with increased weakness and falls. AV's care plan stated that AV was independent with ambulation and transfers, and did not require assistance with safety checks or fall prevention measures. Hospital bed with rails were requested but have not been implemented. Respondent failed to ensure AV's care plan was updated with current information and ensure interventions were in place to reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00350 $500.00 fine assessed