Print Violation: 00380965-AP-335499

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 1/26/2025
Report number: 00380965-AP-335499
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: 411-054-0025(2)
411-054-0027(1)(g) and (s)
411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) had a history of wandering the community and exit seeking. AV was chemically sedated by the facility staff with medication causing AV to sleep more than usual. After a meeting with the facility, it was discovered that at some point at the end of 2024, the facility had switched AV’s scheduled behavior medication to PRN. The medication change had not been approved by AV’s doctor. In January 2025, AV was given PRN pain medication on 7 different occasions on top of his/her scheduled pain medication which was 3 times a day. In January 2025, AV was given PRN anxiety/behaviors medication 8 different occasions on top of his/her scheduled medication which were 3 times a day. The facility failed to provide a safe medication administration system for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00708 $1501.00 fine assessed