Print Violation: 00376371-AP-326791

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 1/1/2025
Report number: 00376371-AP-326791
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) was documented to be a fall risk. Between November 21, 2024, to January 1, 2025, AV sustained nine (9) falls. The interventions for AV falling were increased safety checks and encourage call light use. Despite AV continuously falling, there were no new interventions placed. Facility documents and narrative charting was inconsistent on number of checks per shift, it lists either eight (8) checks or 12. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00693 $1125.00 fine assessed