Print Violation: 00424080-AP-375567

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 8/31/2025
Report number: 00424080-AP-375567
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(G)
Findings: The Alleged Victim (AV) has a history of pressure sores. On or about August 31, 2025, AV was found to have a pressure sore on his/her buttocks with blood present in his/her brief. On or about September 2, 2025, AV had a stage 2 wound on his/her buttocks. Medical staff were not made aware of AV's wound, and no care was provided to the wound to ensure that it didn't worsen. Respondent failed to ensure staff advised medical staff of a change of condition and provide services to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00052 $1000.00 fine assessed