Print Violation: 00313799-AP-276880

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 2/18/2024
Report number: 00313799-AP-276880
Type: Abuse: Neglect
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) received medication that belonged to another resident. Receiving another resident's medication placed AV at risk for serious harm, including low heart rate, cardiac arrest and serious bleeding. The facility failed to contact AV's primary care physician regarding this error, placing AV at risk for serious harm. The facility's failure to ensure AV's physician was contacted placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-00630 $250.00 fine assessed