Print Violation: 00406892-AP-357958

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 1/2/2025
Report number: 00406892-AP-357958
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Alleged Victim’s (AV’s) care plan stated that AV was on a regular diet, but under AV's meal plan it said AV was on a mechanical soft diet. AV's care plan signed on January 7, 2025 - assisted daily living stated AV was "independent' in meals; however, under the needs and services "meals" section it stated AV was a "partial assist." Effective November 15, 2024, AV was put on a mechanical soft food diet. On January 20, 2025, AV was eating an egg in the dining area when AV began choking and gasping for air. Staff performed the Heimlich on AV until AV threw up pieces of egg and began breathing. AV had stopped breathing a second time and staff administered CPR until paramedics arrived. The facility failed to follow the care plan around AV’s diet needs, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01285 $1500.00 fine assessed