Print Violation: 00455697-AP-407840

Provider Information

Klamath Falls Senior Living

2130 N ELDORADO AVE
Klamath Falls, OR 97601

Date: 2/4/2026
Report number: 00455697-AP-407840
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) relied on the facility for care and medication administration and management. On or about February 4, 2026, the facility discovered a bottle of AV's narcotic pain medication to be missing from the medication cart. According to an investigation, narcotic medications were locked inside an area of the locked medication cart, and facility staff were the only ones who had access to the narcotics. Facility staff were completing narcotic medication counts alone, and there were inconsistencies when the last dose was given to the AV. There was no documentation that the medication was destroyed or discontinued. An unknown Alleged Perpetrator 2 (AP2) actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(ii).
Sanction: ALFCP26-00259 $188.00 fine assessed