Print Violation: 00447343-AP-399395

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 12/24/2025
Report number: 00447343-AP-399395
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) has a known history of falls, with reports of approximately three (3) to five (5) falls within the prior six (6) months. On or about December 24, 2025, AV was found on floor; AV had an injury to AV's face. AV was not wearing AV's pendant. It was reported that AV's pendant had been missing for a week. Respondent failed to ensure AV had a functioning pendant for approximately one week prior to the fall despite staff awareness that the pendant was missing, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00401 $500.00 fine assessed