Print Violation: 00392961-AP-343780

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 4/1/2025
Report number: 00392961-AP-343780
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) has a known history of falls. On or about March 27, 2025, Alleged Perpetrator 2 (AP2) directed a care conference for AV at the facility. AV’s service plan and changes in level of care were reviewed. Those present agreed to attempt to decrease 24-hour one-on-one care to 15-minute checks from 6:00am to 6:00pm. On or about April 1, 2025, at approximately 10:00am, AV was found on AV’s fall mat, AV tried to get up by AV’s self. Based on AP2’s position at the time of the incident, AP2 was responsible to make decisions about care for AV. AV’s family was “really advocating” for AV not to be on one-on-one. AP2 failed to provide a safe environment to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00862 $1000.00 fine assessed