Print Violation: 00325019-AP-276525-A

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 4/6/2024
Report number: 00325019-AP-276525-A
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 could not get out of the recliner on his/her own that day and AV winced and grimaced a lot throughout the day. AV was eventually sent to the hospital where it was determined he/she had a broken foot. AP2 failed to protect AV from involuntary seclusion, which is neglect of care and constitutes abuse. The facility failed to protect AV from involuntary seclusion, which is a violation of Oregon Administrative Rules.