Print Violation: 00408230-AP-359283

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 6/15/2025
Report number: 00408230-AP-359283
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)
411-054-0030(1)(e)(H)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is cognitively impaired and requires staff monitoring in common areas and outside. On or about June 15, 2025, AV suffered an unwitnessed fall outside that resulted in AV suffering a fractured clavicle, which caused pain and unreasonable discomfort. Staff were unaware that AV was outside alone for approximately 20 minutes. Respondent failed to ensure staff followed the service plan to ensure AV's safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00173 $1125.00 fine assessed