Print Violation: 00414815-AP-366053

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 7/16/2025
Report number: 00414815-AP-366053
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. AV has chewing difficulty and has a diagnosis of Dysphagia. 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. AV has also been receiving water which has placed AV is risk of aspiration. 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: RCFCP25-01288 $500.00 fine assessed