Print Violation: 00440810-AP-392743

Provider Information

Crystal Terrace Memory Care

320 JADE TERRACE
Klamath Falls, OR 97601

Date: 11/20/2025
Report number: 00440810-AP-392743
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: Alleged Victim (AV) had an extensive fall history and was a high fall risk. On or about November 20, 2025, during weekly skin monitoring, it was discovered that AV had two new marks of discoloration to the back of AV's hand and lower forearm. One was on the top of AV's right hand measuring 0.5 cm x 0.5 cm, red/purple in color, and the skin was intact. Another was to the lower right forearm measuring approximately 2 cm x 1 cm, purple/brown in color. Respondent failed to provide a safe environment for AV, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00400 $375.00 fine assessed