Print Violation: 00362608-AP-312863

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 9/30/2024
Report number: 00362608-AP-312863
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On or about September 30, 2024, AV was found on the floor next to his/he bed in the fetal position. Prior to September 30th, 2024, AV had a fall on September 19, 2024, outside of AV’s bedroom, and on August 5, 2024, AV was found on the floor next to AV’s bed. There were concerns that AV’s bed was not adequate for AV as it was tall, which sat higher off the ground. AV’s bed also made it hard to assist AV with transfer. The facility was aware AV’s bed was a concern and a fall risk to AV, but no action was taken. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00614 $500.00 fine assessed