Print Violation: 00396457-AP-347102

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 4/18/2025
Report number: 00396457-AP-347102
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
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)
411-054-0070(1)
Findings: The Alleged Victim (AV) is a known fall risk. On or about April 18, 2025, AV was found on the floor of his/her apartment covered in blood with a head wound and covered in feces. AV is care planned to be checked on for safety 8 times per shift. Staff called emergency services, and it was noted that it appeared AV had been on the floor for some time. It was determined the last check on AV was at 4:00 am, so AV had been on the floor for at least 6 hours. Staff noted that the facility was short staffed. AV was transported to the hospital where he/she received staples to his/her forehead to treat the laceration. The Respondents failure to follow the care plan for AV's risk of falls caused AV to lay on the floor for multiple hours with an injury to his/her head. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00033 $375.00 fine assessed