Print Regulatory Action: CALMS - 00082158

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Effective date: 7/1/2025
End date: 8/13/2025
Reference number: CALMS - 00082158
Allegation: Failed to properly plan care
Description: AV was on 24-hour oxygen as part of AV's care plan. AV was left with h/h oxygen tube under h/h back for so long that it left red and purple marks on h/h back. AV was not able to adjust h/h oxygen tube on h/h own. AV's oxygen tube was not on h/h face. AV was bedbound and at the end of life. AV was unable to eat or drink on h/h own. AV passed away the day s/he was found with h/h tube imprinted on h/h back. AV was on 1-1 care leading up to h/h passing. APS Investigation was initiated. APSS responded 06/16/25 and spoke with Executive Director, Jacob McMurrin. Jacob did not have any information regarding AV's care plan or temporary service plans. Jacob could not remember specifically if AV was on 1-1 care leading up to h/h passing. Jacob knew that AV passed away the week prior; however, did not know what day. Jacob stated that he had been working on the care plans for residents with Tosha, the interim director, for residents in the facility. Jacob also stated that he was working on increasing staffing levels by hiring more people for the facility as staff had complained about being short staff and unable to complete all care tasks like laundry for residents.
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Facility failed to properly care plan
Sanction: RCFCD25-00675