Inspection Reports for Pelican Pointe Assisted Living
615 Washburn Way, Klamath Falls, OR 97603, OR, 97603
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Inspection Report
Capacity: 48
Deficiencies: 40
Oct 17, 2024
Visit Reason
State-compiled facility profile showing 4 inspections from 2021 to 2024 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2024, the facility exhibited numerous deficiencies including failure to maintain sanitary conditions, inadequate staffing, incomplete resident service plans, failure to follow physician orders, insufficient infection control, and lack of proper administrative oversight. Some deficiencies were corrected over time while others remained uncorrected at the time of the latest inspections.
Deficiencies (40)
| Description |
|---|
| C0000 - Comment: General comments and overview of inspection findings. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner including debris on can opener blade, peeling paint on doors, open sprinkler head areas, and poor infection control practices. |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were in routinely accessible and conspicuous locations. |
| C0154 - Facility Administration: Policy & Procedure: Failed to develop and implement effective methods of responding to and resolving resident complaints. |
| C0242 - Resident Services: Activities: Failed to ensure daily program of social and recreational activities based on resident interests and needs. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial evaluation addressed all required elements for sampled resident. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' care needs and provided clear direction to staff. |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks in accordance with OSBN rules for insulin administration. |
| C0361 - Acuity-Based Staffing Tool: Failed to ensure ABST included evaluated care needs of all residents and was completed before move-in. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure newly hired staff completed required pre-service orientation and dementia training. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct-care staff demonstrated satisfactory performance within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and provide fire and life safety instruction on alternate months. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to have system for instructing residents on fire safety within 24 hours of admission and annually. |
| C0510 - General Building Exterior: Failed to ensure grounds were orderly, free of litter, chemicals secured, and measures to prevent entry of pests. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep all interior materials and surfaces clean and in good repair. |
| C0515 - Resident Units: Failed to ensure residents' rooms had lockable storage space with keys provided. |
| C0540 - Heating and Ventilation: Failed to ensure heating elements did not exceed 120 degrees Fahrenheit where incidental contact possible. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide exit door alarms or acceptable system to alert staff when residents exited. |
| H1501 - Integrated Settings: Community Life: Provided technical assistance regarding integration and community access. |
| H1512 - Optimize Settings: Independence, Activities: Provided technical assistance regarding autonomy and independence in life choices. |
| H1515 - Physical Setting: Individual Accessible: Provided technical assistance regarding physical accessibility of setting. |
| H1517 - Individual Privacy: Own Unit: Provided technical assistance regarding privacy in own unit related to lack of locks on shared bathroom doors. |
| C0155 - Facility Administration: Records: Failed to maintain complete and accurate records for sampled residents including skin breakdown and urinary tract infection. |
| C0160 - Reasonable Precautions: Failed to implement effective infection control methods, including improper glove use and hand hygiene. |
| C0200 - Resident Rights and Protection - General: Failed to protect residents from neglect including toileting assistance and monitoring weight loss. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause and suspected abuse to local authorities and conduct timely investigations. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a team including resident and administrator. |
| C0270 - Change of Condition and Monitoring: Failed to monitor residents consistent with evaluated needs and service plans after changes of condition. |
| C0280 - Resident Health Services: Failed to ensure RN assessments documented findings and interventions for severe weight loss. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed including medication and diet orders. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included specific instructions for PRN medications. |
| C0315 - Systems: Treatment Administration: Failed to keep accurate treatment records for treatments ordered and administered. |
| C0350 - Administrator Qualification and Requirements: Failed to employ full-time administrator scheduled at least 40 hours per week. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient caregivers to meet 24-hour scheduled and unscheduled resident needs. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| Z0140 - Administration Responsibilities: Failed to provide effective administrative oversight over Memory Care Community operations. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| Z0155 - Staff Training Requirements: Failed to ensure all pre-service orientation and annual training were completed and documented for staff. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0164 - Activities: Failed to develop individualized activity plans based on activity evaluations and provide meaningful activities. |
Report Facts
Inspections on page: 4
Total deficiencies: 47
Licensing violations: 20
Notices: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Murphy | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director (ED) | Named in multiple findings and acknowledgements across inspections |
| Staff 3 | Executive Chef | Named in kitchen inspection findings |
| Staff 4 | Business Office Manager (BOM) | Named in staff training and pre-service orientation findings |
| Staff 5 | Environmental Services Director (ESD) | Named in multiple environmental and fire safety findings |
| Staff 6 | Regional RN | Named in multiple clinical and administrative findings |
| Staff 9 | Medication Technician (MT) | Named in delegation and training deficiencies |
| Staff 10 | Caregiver (CG) | Named in training and competency deficiencies |
| Staff 19 | Executive Director / ALF | Named in multiple findings related to Memory Care Community |
| Staff 20 | Resident Care Coordinator (RCC) | Named in multiple findings related to Memory Care Community |
| Staff 29 | Executive Chef | Named in kitchen sanitation findings |
| Staff 30 | Executive Director | Named in follow-up and administrative findings |
| Staff 32 | Resident Care Coordinator (RCC) | Named in service plan and staffing findings |
| Staff 33 | Caregiver (CG) | Named in staff competency findings |
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