Print Violation: 00419794-AP-371150

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 8/10/2025
Report number: 00419794-AP-371150
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility to administer his/her medication. On or about August 10, 2025, AV was administered insulin incorrectly by Alleged Perpetrator 2 (AP2). AP2 received online training and in-person supervision for AP2's position. AP2 was delegated to administer insulin on August 7, 2025. On August 10, 2025, the parameters for administering AV's insulin were not followed by AP2. AP2 failed to provide a safe medication administration system to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.
Sanction: RCFCP26-00041 $375.00 fine assessed