Print Violation: 00414794-AP-366035

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 7/16/2025
Report number: 00414794-AP-366035
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: Alleged Victim (AV) was on a puree food and thickened liquid diet per his/her care plan. The facility has a history of not following diet restrictions. On or about June 27, 2025, the facility received instructions from PCP to continue to offer diet of pureed food with nectar thickened liquids due risk of aspiration. As of July 16, 2025, AV was being served ice cream as part of his/her diet under the misimpression that it qualifies as a thickened liquid which place AV at risk of aspiration. On or about July 22, 2025, facility staff attempted to give an ice cream sandwich. Two weeks prior to the incident with AV, facility staff tried to serve chicken salad to mechanical soft residents. The facility failed to assure AV’s care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01287 $375.00 fine assessed