Print Violation: 00392961-AP-343587

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 4/1/2025
Report number: 00392961-AP-343587
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Between January 6th to 29th, 2025, Alleged Victim (AV) had 13 falls. AV’s one-on-one was removed on March 31, 2025. On or about April 1, 2025, at approximately 10 am, AV was found on AV’s falls mat because AV tried to get up by AV’s self. The facility acknowledged AV’s fall could have been avoided with one-on-one care, it was not a good idea to remove AV’s one-on-one because AV could decide to get up and fall. The facility failed to provide service for AV by failing to assure the necessary supervision to prevent AV from falling, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00862 $1000.00 fine assessed