Print Violation: 00322286-AP-321508

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 12/15/2023
Report number: 00322286-AP-321508
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to protect resident from involuntary seclusion
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) is wheelchair-bound and requires full assist with mobility and transfers. On or about November 2, 2023, it was decided to keep AV’s wheelchair away from AV to keep him/her from attempting to self-transfer. Alleged Perpetrator 3 (AP3) decided to keep AV’s wheelchair away from AV, however, keeping AV’s wheelchair away from AV was a restraint. AP3 failed to protect AV from involuntary seclusion, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from involuntary seclusion, which is a violation of Oregon Administrative Rules.
Sanction: RCFCP25-00157 $500.00 fine assessed