Print Violation: 00386889-AP-339562

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 3/1/2025
Report number: 00386889-AP-339562
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On or about January 15, 2025, AV’s doctor noted AV’s coccyx wound was a “healed pressure sore still considered stage 1 due to redness.” Between February 11th through the 19th, 2025, AV’s skin was noted to be clear. On or about March 2, 2025, staff reported AV had redness/sore on AV’s left buttocks. On or about March 12, 2025, AV had blanchable redness to buttocks with 1 cm long open area to coccyx. Staff believed AV was supposed to be checked every two hours and were supposed to toilet AV every two hours, but not all staff changed AV every two hours. AV developed a sore as a direct result of AV not being toileted or repositioned as often as AV needed, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-00926 $500.00 fine assessed