Print Violation: 00382859-AP-333323

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 2/4/2025
Report number: 00382859-AP-333323
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) known history of unsteady gait and non-compliance with using their call light for assistance for transfers. On or about February 04, 2025, the AV suffered a non-injury fall in the facility. After this fall, the facility implemented 8 safety checks per 12-hour shift on the AV. Approximately three days later, on or about February 07, 2025, the AV was put in bed for a nap at approximately 1:30 pm. Around 3:00 pm, staff checked on the AV and found them sitting on the floor next to their bed, complaining of back pain. There is no documented evidence the facility implemented appropriate interventions for the AV’s increase in falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP25-00682 $375.00 fine assessed