Print Violation: 00398870-AP-349577

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 4/30/2025
Report number: 00398870-AP-349577
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On or about April 30, 2025, Hospice staff discovered bruising on both of AV's legs. AV also had red spot bruises on the top of both of AV's hands and right upper arm. AV used a hospital bed with half rails for turning and repositioning due to immobility/pain, and general decline. AV was to have both left and right half side bed rails, placed in full up and locked position while in bed. However, the side rails could increase the risk of skin tears, limb discoloration or dismemberment, suffocation and death. There were no interventions to prevent/decrease the risk of skin tears and limb discoloration, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01184 $500.00 fine assessed