Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00455668-AP-407825
Provider Information
Crystal Terrace Memory Care
320 JADE TERRACE
Klamath Falls, OR 97601
- Provider ID
- 50M300
- Administrator
- Rachel Vandusen
- Phone
- (541) 273-7336
- rachelvandusen@mbk.com
Violation Details
- Date
- 11/21/2025
- Report number
- 00455668-AP-407825
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(I)
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. Staff witnessed Witness 1 (W1) grabbed and kissed AV, but no timeline was provided. W1 confused AV for W1’s spouse and W1 might have tried to touch or kiss AV. Between November 22, 2025, and February 3, 2026, W1 had ongoing behaviors toward residents of the opposite gender where W1 kissed them, held their hands, rubbed their backs, pulled their arms and spanked their butts. Alleged Perpetrator 2 (AP2) oversaw "all of the things" at AP1 including writing, updating and reviewing service plans and safety plans for residents. AP2 managed all operations to meet the specific needs of all residents. AP2 oversaw resident wellness services, environmental safety and family support. AP2 was required to comply with all federal, state and local regulations, and all AP1 company policies and procedures. However, AP2 did not take any steps to protect AV from W1 because staff did not report concerns to AP2 regarding W1 and residents of the opposite gender, which is neglect of care and constitutes abuse. Respondent failed to implement meaningful interventions for behaviors for W1, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00406 $500.00 fine assessed