Print Violation: 00427536-AP-379194

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 9/17/2025
Report number: 00427536-AP-379194
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) relies on the facility for his/her care needs. AV was found to have a new area of skin impairment on 9/17/2025 located on the right gluteal cleft measuring approximately .3cm x .3cm, purple in color, fluid filled, and not open. AV was prescribed a barrier cream, which was inconsistently documented as administered, with limited applications recorded in September 2025 despite daily orders. There were discrepancy and lack of clarity in medication orders and documentation regarding which skin treatments were to be applied and when. Respondent failed to implement a safe medication administration system, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00200 $500.00 fine assessed