Print Violation: 00250128-AP-205924

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 3/5/2023
Report number: 00250128-AP-205924
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
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)
Findings: The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) change of condition. Investigation revealed that AV had a non-injury fall on or about February 24, 2023, and began to decline. AV refused to eat, was unsteady on his/her feet, needed additional hands-on assistance and was admitted to hospice. Despite AV’s behavioral changes, and lack of eating, AV’s care plan was not updated and still showed AV independent with ambulation and transferring and only required one check per shift. On or about March 5, 2023, AV suffered a fall and was sent to the hospital and diagnosed with a broken hip. AV was not a good candidate for surgery and was discharged back to the facility. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP23-01557 $500.00 fine assessed