Print Violation: 00358040-AP-308399

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 9/21/2021
Report number: 00358040-AP-308399
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(A)
411-054-0070(1)
Findings: The Alleged Victim (AV) is care planned as a two person assist with transfers. On or about September 21, 2024, AV had a witnessed assisted fall in his/her room. Alleged Perpetrator #2 (AP2) was assisting AV with a transfer by him/herself, due to the facility not having enough staff to ensure two staff were available to assist with the transfer. AP2 was not able to complete the transfer by themselves and ended up assisting AV to the floor. AV was not injured. The Respondents failure to ensure proper staffing placed AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00028 $250.00 fine assessed