Inspection Reports for Klamath Falls Senior Living
2130 N Eldorado Ave, Klamath Falls, OR 97601, United States, OR, 97601
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Inspection Report
Capacity: 70
Deficiencies: 30
Apr 1, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failures in food sanitation, resident health services, administration oversight, infection control, staffing, service planning, medication administration, and fire and life safety. Many deficiencies were repeated or ongoing with plans of correction in place.
Complaint Details
The document includes complaint investigations such as Survey 8R09 dated 2024-10-16 and Survey 6R0E dated 2023-05-04, detailing failures in resident health services and licensing complaints including failure to report incidents to local SPD office.
Deficiencies (30)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food was stored and kitchen maintained according to Food Sanitation Rules. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0150 - Facility Administration: Operation: Failed to ensure adequate administrative oversight of facility operations and staff supervision. |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints. |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs evaluating services and resident satisfaction. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety, or welfare of residents with modified diets and swallowing risks. |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect related to pervasive odors, late meal delivery, and room damage. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report injuries of unknown cause and allegations of abuse. |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure resident evaluations were complete, timely, and addressed required elements. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected current care needs, were clear, and readily available to staff. |
| C0270 - Change of Condition and Monitoring: Failed to have reporting protocol and monitor changes of condition appropriately. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed for residents with significant changes of condition. |
| C0295 - Infection Prevention & Control: Failed to establish and maintain effective infection prevention protocols and designate qualified Infection Control Specialist. |
| C0303 - Systems: Treatment Orders: Failed to carry out physician orders as prescribed and obtain signed orders for medications and treatments. |
| C0310 - Systems: Medication Administration: Failed to keep accurate MARs including reasons for use and resident-specific parameters for PRN medications. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate residents' ability to self-administer medications quarterly. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had written resident-specific parameters and documented non-drug interventions. |
| C0340 - Restraints and Supportive Devices: Failed to ensure supportive devices were assessed and caregivers instructed on proper use. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to consistently staff according to posted staffing plan. |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to ensure proprietary ABST was Department-approved. |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements in ABST for sampled residents. |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update ABST evaluations with significant changes and quarterly. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure caregiving staff demonstrated competency within 30 days of hire. |
| C0374 - Annual and Biennial Inservice for All Staff: Failed to ensure staff completed required annual in-service training including dementia and infectious disease training. |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction on alternate months and conduct unannounced fire drills per Oregon Fire Code. |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents were re-instructed annually on fire and life safety procedures. |
| C0610 - General Building Exterior: Failed to maintain courtyard surfaces and pathways in good repair and keep grounds orderly. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to maintain environment clean and in good repair including walls, doors, floors, and odors. |
| H1511 - Individual Rights Settings Right to Freedom: Failed to ensure individuals had right to freedom from restraints. |
| C0000 - Comment: Various comments related to inspections and compliance status. |
Report Facts
Inspections on page: 6
Total deficiencies: 59
Total surveys: 6
Licensing violations: 10
Notices: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krystal Cleveland | Administrator | Named in multiple findings and plan of correction acknowledgments |
| Staff 1 | Executive Director | Named in multiple findings, interviews, and plan of correction acknowledgments |
| Staff 2 | Operations Specialist | Named in multiple findings, interviews, and plan of correction acknowledgments |
| Staff 3 | Regional Director of Operations / Regional Vice President of Operations | Named in multiple findings and plan of correction acknowledgments |
| Staff 4 | Regional Business Office Manager | Named in multiple findings and plan of correction acknowledgments |
| Staff 5 | Business Office Manager / Medication Technician | Named in findings related to complaint handling and medication administration |
| Staff 6 | Maintenance Director | Named in findings related to fire safety and building maintenance |
| Staff 7 | Resident Care Coordinator | Named in findings related to service plans and training |
| Staff 8 | Medication Technician / Personal Care Assistant | Named in findings related to training and medication administration |
| Staff 9 | Cook / Personal Care Assistant | Named in findings related to diet and meal service |
| Staff 10 | Personal Care Assistant | Named in findings related to training |
| Staff 11 | Cook | Named in findings related to diet and meal service |
| Staff 12 | Medication Technician | Named in findings related to resident care and diet |
| Staff 13 | Medication Technician | Named in findings related to resident care and incident reporting |
| Staff 14 | Personal Care Assistant | Named in findings related to resident care and diet |
| Staff 15 | Personal Care Assistant | Named in findings related to training and resident care |
| Staff 17 | Acting Dietary Manager / Cook | Named in findings related to diet and meal service |
| Staff 19 | Medication Technician / Personal Care Assistant | Named in findings related to resident care and infection control |
| Staff 20 | Personal Care Assistant | Named in findings related to training |
| Staff 21 | Personal Care Assistant | Named in findings related to training |
| Staff 22 | Personal Care Assistant | Named in findings related to training |
| Staff 23 | Medication Technician | Named in findings related to training and medication administration competency |
| Staff 24 | Personal Care Assistant | Named in findings related to infection control and training |
| Staff 25 | Medication Technician | Named in findings related to annual training |
| Staff 26 | Dishwasher | Named in findings related to annual training |
| Staff 27 | Concierge | Named in findings related to complaint handling |
| Staff 28 | Medication Technician | Named in findings related to annual training |
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