Print Violation: 00367052-AP-317288

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 11/18/2024
Report number: 00367052-AP-317288
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk and had suffered previous falls with and without injury. On or about November 18, 2024, staff responded to AV's call light and found AV on the floor sitting position, with his/her back to his/her bed. AV was a one-person assist with transfers, however, there was no documentation indicating how staff were to implement it. AV tied to get up on his/her own and ambulate, which caused many of AV's falls. Respondent failed to implement interventions to reduce AV's risk of falls and ensure staff were aware how to enact the interventions that were in place. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00114 $375.00 fine assessed