Print Violation: 00415908-AP-367177

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 7/23/2025
Report number: 00415908-AP-367177
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
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) had falls prior to the update of his/her service plan on July 16, 2025, but the service plan stated no falls in the fall history. On or about May 29, 2025, AV was found with an injury to his/her forehead and elbow area. AV was sent to the ER for the injury. On or about June 12, 2025, AV had an unwitnessed fall, however there was no other documentation or interventions for this fall. On or about July 2, 2025, AV had a fall according to a TSP, however there was no incident report or narrative charting describing the incident or interventions. On or about July 23, 2025, AV was seen in the emergency room for a fall that resulted in a cut on h/h eyebrow. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01313 $1125.00 fine assessed