Print Violation: 00428533-AP-380227

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 9/22/2025
Report number: 00428533-AP-380227
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate 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) had been hospitalized and was discharged on or about September 15, 2025. AV was found to have an open area/pressure injury on the top right side of h/h buttocks which was open, red, and leaking bodily fluid when discovered on or about September 22, 2025. The pressure injury had been covered by a bandage that fell off, revealing the open area of skin. The bandage observed was not a type used by facility staff and was believed to have been applied at the hospital at least a week prior. Facility staff were aware that AV had a bandage on his/her buttocks but failed to report it to a med tech or nurse for at least a week after hospital discharge. Respondent failed to implement meaningful interventions for wound care, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00398 $250.00 fine assessed