Print Violation: 00398442-AP-349126

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 4/3/2025
Report number: 00398442-AP-349126
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) receives his/her medication from the facility. On or about April 30, 2025, AV was placed on alert for being given his/her insulin incorrectly. AV was to have his/her blood sugar levels checked to determine which, if any, insulin to give AV. On multiple occasions, AV was given the incorrect insulin, or no insulin at all, placing AV at risk for harm. The Respondents failure to provide a safe medication administration system placed AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00034 $188.00 fine assessed