Print Violation: 00372357-AP-323221

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 12/17/2024
Report number: 00372357-AP-323221
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medication. On or about November 12, 2024, an antipsychotic was prescribed to AV in anticipation of AV being moved to help AV cope with the change. On or about December 9, 2024, it was discovered that the facility was not administering AV’s antipsychotic medication properly. AV was supposed to be getting a total of 75 mg every time it was administered, but AV was only getting 50 mg. The facility failed to provide a safe medication administration system for AV by failing to monitor AV when there was a medication change, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00689 $1313.00 fine assessed