Print Violation: 00377893-AP-328317

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 12/24/2024
Report number: 00377893-AP-328317
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 December 2024, the facility overmedicated AV using the liquid narcotic so much more than AV’s previous living arrangement. The facility used the narcotic because it was more convenient to use, and it worked quickly. AV had an escalation in use of the narcotic. AV was given the narcotic a total of 19 times in December 2024. There were two (2) other “as needed” medications available for AV; 1 was for agitation and the other was for pain. Those were given to AV a total of three (3) times in December 2024. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01069 $500.00 fine assessed