Print Violation: 00413879-AP-365167

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 7/13/2025
Report number: 00413879-AP-365167
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’s (AV’s) care plan notes he/she is independent with ambulation, is known to refuse showers, and staff must attempt a change of face if AV refuses and has confusion as well as hallucinations. On or about July 13, 2025, AV was found to have a wound and the bandage was soiled. Facility staff did not notify any other staff, begin a TSP or initiate alert charting. It was unknown what caused the injury to AV or when. AV's wound smelled horrible, and the bandage was stuck to the skin and appeared to be growing onto the bandage. The facility failed to care plan around AV’s refusal to showers and to provide appropriate care around the wound that was found, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP25-01282 $500.00 fine assessed