Print Violation: 00399602-AP-350357

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 5/3/2025
Report number: 00399602-AP-350357
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Facility staff were to provide Alleged Victim (AV) two-person assistance for all ambulation. On May 3, 2025, AV was in AV's wheelchair. An in-home agency (IHA) staff and facility staff walked with AV back to AV's room. The facility staff briefly left Witness 5 (W5) while W5 wheeled AV into AV's room and closed the room door. AV stood up from AV's wheelchair and grabbed the IHA staff by the shoulder. AV became dead weight and W5 assisted AV to the ground. AV’s care plan stated that staff were to be present at all times to ensure AV’s safety. The facility failed to follow the care plan around two-person assist for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01272 $500.00 fine assessed