Print Violation: 00325019-AP-276525

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 4/6/2024
Report number: 00325019-AP-276525
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for all care needs. On or about April 6, 2024, during shift change, night shift informed day shift that AV had a swollen, purple foot and that AV complained of pain. Staff suspected the foot was broken. Staff requested AV be sent to the hospital, but Alleged Perpetrator 2 (AP2) denied the request because the facility was short-staffed that day. AP2 directed staff to put AV in a recliner and elevate AV’s foot. AV went back and forth between wanting to go and not wanting to go to the hospital, however, per facility’s policy, the facility does not wait for permission from a resident or responsible party to send a resident to the hospital. AP2 said they would try to get a hold of someone to take AV to the hospital but AP2 never did. AP2 failed to provide service for AV but not getting AV to the hospital in a timely manner, which is neglect of care and constitutes abuse. The facility failed to assure AV received proper service, which is a violation of Oregon Administrative Rules.