Print Violation: 00227389-AP-185664

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 10/17/2022
Report number: 00227389-AP-185664
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0070(2)
Findings: On or about October 17, 2022, the Alleged Victim (AV) suffered a fall in his/her room while being transferred by Alleged Perpetrator #2 (AP2). AV sustained a skin tear during this fall. AV is care planned to be transferred with a gait belt. AP2 did not use a gait belt during the transfer of AV. AP2 was not trained to use the gait belt with AV and was not trained to look at residents care plan to understand the residents needs. The facility's failure to properly train staff and follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP23-00367 $250.00 fine assessed