Print Violation: 00427547-AP-379213

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 9/16/2025
Report number: 00427547-AP-379213
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) has a known history of skin breakdown. On or about September 15, 2025, AV was found to have an open area of skin on h/h left buttocks near the gluteal cleft measuring approximately 2cm x 1.9cm that was red and leaking bodily fluid. The surrounding tissue on both buttocks was red and irritated. The wound appearance was consistent with a pressure-related or friction-related injury. Respondent failed to report that AV had open skin area and skin monitoring was discontinued despite AV’s documented history of recurring skin breakdown, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00210 $500.00 fine assessed