Print Violation: 00313799-AP-266155

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 2/18/2024
Report number: 00313799-AP-266155
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: On or about February 18, 2024, the Alleged Victim (AV) was given medication that belonged to another resident. Alleged Perpetrator #2 (AP2) went to the medication cart and grabbed medication for a different resident and gave it to AV. AV was placed at risk of serious harm from receiving another residents medication. The next day, AV was reported to have been incontinent of bowel and was lethargic. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.
Sanction: RCFCP24-00630 $250.00 fine assessed