Print Violation: 00380965-AP-331510

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 1/26/2025
Report number: 00380965-AP-331510
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0025(2)
411-054-0027(1)(g) and (s)
Findings: Alleged Victim (AV) is known to be a high fall risk. Between January 26th through 28th, 2025, AV had four (4) falls. On the incident report dated January 26, 2025, it was noted that the fall could have been avoided with possible 1-1 care for AV, which meant that the facility was aware of the proper intervention but failed to implement it. AV was not place on a change in condition or 1-1 care until January 31, 2025, after falling nine (9) times in January 2025. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times and placed AV at risk of serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00708 $1501.00 fine assessed