Print Violation: 00382343-AP-332873

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 2/4/2025
Report number: 00382343-AP-332873
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Alleged Victim (AV) has a known history of falls. Between November 2024, through February 2, 2025, AV sustained nine (9) falls, eight (8) of the nine (9) falls occurred in the late afternoon and evening. Six (6) out of the nine (9) falls occurred in common areas while AV was ambulating. On or about February 4, 2025, at around 6:45 pm, AV pushed AV’s walker up against the closed med tech office door and fell. AV hit AV’s forehead on the cushioned part of AV’s walker. The facility failed to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01073 $500.00 fine assessed