Print Violation: 00424080-AP-377254

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 8/31/2025
Report number: 00424080-AP-377254
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(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. On or about September 11, 2025, AV's wound was larger. No new interventions were put into place to reduce the risk of further wound worsening. Respondent failed to ensure interventions were put into place to decrease the worsening of AV wound, or to ensure AV would not have new wounds. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00052 $1000.00 fine assessed