Print Violation: 00417918-AP-369243

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 7/15/2025
Report number: 00417918-AP-369243
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0040(1)(a) and (d)
Findings: The Alleged Victim (AV) suffered 7 falls between June 4, 2025, and July 15, 2025, with and without injury. On or about June 26, 2025, AV had a significant change of condition. AV's care plan was not updated to reflect AV's need to have stand by assistance with transfers or any interventions regarding AV's safety with his/her recliner, bed and toilet to reduce falls. Respondent failed to ensure proper care planning and that interventions were in place to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00039 $1000.00 fine assessed