Print Violation: 00390165-AP-340844

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 3/17/2025
Report number: 00390165-AP-340844
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)
411-054-0030(1)(e)(A)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is a known fall risk. Between February 12, 2025, and March 17, 2025, AV suffered 5 falls. AV was care planned to use an assistive device to ambulate, however, AV either forgot to use it or not like to use it. AV was care planned for stand by assist while ambulating. Facility documentation does not note interventions nor record multiple falls that occurred. The Respondents failure to properly care plan for AV's risk of falls caused AV to suffer bruises and skin tears. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00030 $250.00 fine assessed