Print Violation: 00417918-AP-379887

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 7/15/2025
Report number: 00417918-AP-379887
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)
Findings: The Alleged Victim (AV) suffered 2 falls between July 26, 2025, and July 28, 2025. AV's care plan was not updated to reflect AV's need to have stand by assistance with ambulation and transfers. AV's care plan was not updated until July 31, 2025. AV continued to fall through August 28, 2025, with two more 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