Print Violation: 00399848-AP-350633

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 5/5/2025
Report number: 00399848-AP-350633
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: On or about May 5, 2025, the Alleged Victim (AV) was found with a .4 cm sore on his/her buttocks. AV was care planned to be changed every two hours and were supposed to place a pressure reducing cushion under AV to alleviate pressure on the area. Staff did not follow AV's care plan as AV was found multiple times caked in bowel and urine. Respondent failed to ensure staff followed the care plan. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00017 $375.00 fine assessed