Crystal Terrace

Alleged Victim (AV) relies on the facility for his/her care needs. On or about May 14, 2025, at approximately 5:10am, AV was found on the floor with his/her head against the bed frame after reportedly sliding from bed. AV was care planned for 15-minutes checks, however, staff failed to consistently complete 15-minutes checks. Respondent failed provide a safe environment to AV. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(A)(ii) and violates the following OARs:

Alleged Victim (AV) relies on the facility for his/her care needs. On or about May 25, 2025, AV sustained a fall. AV had six (6) falls, one on or about May 3, 2025, two (2) on or about May 14th, 15th, and 16th, 2025. Prior to May 2025, AV was reportedly more independent; however, following a medical diagnosis in late April or early May 2025, AV experienced a rapid decline. Respondent failed to provide a safe environment to AV, resulting in several falls. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(A)(ii) and violates the following OARs:

The Alleged Victim (AV) suffered and unwitnessed fall in his/her bathroom and was found on the floor between the toilet and the wall. AV suffered pain and redness to his/her knees. AV may have fallen due to a bathmat being on the floor, causing AV to trip and fall. Staff had seen and picked up the bathmat in the past to prevent falls; however, the bathmat was found on the floor at the time of this incident. Respondent failed to provide a safe environment. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

The Alleged Victim (AV) is a known fall risk. On or about April 18, 2025, AV was found on the floor of his/her apartment covered in blood with a head wound and covered in feces. AV is care planned to be checked on for safety 8 times per shift. Staff called emergency services, and it was noted that it appeared AV had been on the floor for some time. It was determined the last check on AV was at 4:00 am, so AV had been on the floor for at least 6 hours. Staff noted that the facility was short staffed. AV was transported to the hospital where he/she received staples to his/her forehead to treat the laceration. The Respondents failure to follow the care plan for AV's risk of falls caused AV to lay on the floor for multiple hours with an injury to his/her head. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) receives his/her medication from the facility. On or about April 30, 2025, AV was placed on alert for being given his/her insulin incorrectly. AV was to have his/her blood sugar levels checked to determine which, if any, insulin to give AV. On multiple occasions, AV was given the incorrect insulin, or no insulin at all, placing AV at risk for harm. The Respondents failure to provide a safe medication administration system placed AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk. On or about March 27, 2025, and March 30, 2025, AV suffered 3 falls. AV was care planned for safety checks 8 times per shift. AV suffered a rug burn and scratches to his/her lower back. The Respondents failure to properly care plan for AV's risk of falls caused AV to suffer a rug burn and scratches. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk. Between February 12, 2025, and March 17, 2025, AV suffered 5 falls. AV was care planned to use an assistive device to ambulate, however, AV either forgot to use it or not like to use it. AV was care planned for stand by assist while ambulating. Facility documentation does not note interventions nor record multiple falls that occurred. The Respondents failure to properly care plan for AV's risk of falls caused AV to suffer bruises and skin tears. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care. On or about January 2025, AV invited Witness 5 (W5) into his/her apartment where W5 began rubbing AV’s hands without consent. AV described the interaction as “grooming” and stated he/she did not want a relationship with W5. AV asked W5 to leave, and W5 complied without further incident. On or about January 9, 2025, AV disclosed the incident to staff. Alleged Perpetrator 3 (AP3) “thought” the incident had been reported to APS. AP3 also said that he/she did not think the incident needed to be reported due to no negative outcome. AP3 was not aware that W5 touching AV's stomach was considered sexual abuse. AP3 failed to provide a safe environment to AV. Respondent failed to provide a safe environment, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) had a history of falling out of bed. AV was care planned to have a wedge and a call system in place to assist with safety. On or about January 13, 2024, AV was experiencing more anxiety than usual and was trying to get out of bed. AV is prescribed an as needed anxiety medication. On that same evening, AV was found on the floor in his/her room, it is assumed AV fell from bed. AV was given his/her anxiety medication after the fall instead of earlier in the evening when he/she was experiencing the anxiety. AV's care plan does not address AV's anxiety and agitation. If the care plan had noted it, it may have lead staff to ensure AV received the anxiety medication earlier. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV described the way that Alleged Perpetrator 2 (AP2) was touching his/her hair in a sexual manner and compared it to how AV’s deceased spouse would when he/she was younger. AV stated this made him/her feel uncomfortable. During an interview with AP2, AP2 admitted to touching AV’s hair. Alleged Perpetrator 3 (AP3) had experience at the local management level at the facility and had been trained in reporting abuse. AP3 said that he/she had heard from employees that AP2 was “creepy”. AP3 had knowledge of a resident making a complaint about AP2. AP3 acknowledged that something should have been done about AP2 being able to continue caring for residents. AP2 and AP3 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. In the middle of August 2023, AV disclosed information of a staff member touching AV’s chest. AV did have sighs of emotional impact from the alleged incident. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) change of condition. Investigation revealed that AV had a non-injury fall on or about February 24, 2023, and began to decline. AV refused to eat, was unsteady on his/her feet, needed additional hands-on assistance and was admitted to hospice. Despite AV’s behavioral changes, and lack of eating, AV’s care plan was not updated and still showed AV independent with ambulation and transferring and only required one check per shift. On or about March 5, 2023, AV suffered a fall and was sent to the hospital and diagnosed with a broken hip. AV was not a good candidate for surgery and was discharged back to the facility. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 17, 2022, the Alleged Victim (AV) suffered a fall in his/her room while being transferred by Alleged Perpetrator #2 (AP2). AV sustained a skin tear during this fall. AV is care planned to be transferred with a gait belt. AP2 did not use a gait belt during the transfer of AV. AP2 was not trained to use the gait belt with AV and was not trained to look at residents care plan to understand the residents needs. The facility's failure to properly train staff and follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have service plans reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence in accordance with OAR 411-054-0036(2); which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to have service plans reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence in accordance with OAR 411-054-0036(2); which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f), which is a violation of Oregon Administrative Rules.

The facility failed to ensure the medication record for each resident that the facility administers medications to included specific instructions and resident specific parameters and instructions for p.r.n. medications in accordance with OAR 411-054-0055(2), which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request in accordance with OAR 411-054-0105(1)(a) which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. According to an investigation, on or about February 17, 2025, it was discovered that an unknown Alleged Perpetrator 2 (AP2) had taken $150 from AV's purse. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep the AV free from financial exploitation, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 2, 2024, feces was found on AV’s forehead. It is believed Alleged Perpetrator 2 (AP2) was the individual who smeared feces on AV since he/she was working the day that AV had feces place on his/her forehead. In addition, staff recorded AP2 wiping feces on a dryer on the facility as well as holding gloves full of feces. AP2 appeared to have feces on his/her hands, as well as tucking a glove of feces in his/her shirt pocket. AP2 failed to protect AV from emotional abuse by placing feces on AV’s forehead, which neglect of care and constitutes abuse. The facility failed to protect AV from emotional abuse, which is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1) per complaint that call lights are not answered timely and residents wait for assistance for 40+ minutes, which is a violation of Oregon Administrative Rules.

On or about May 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2023, to April 30, 2023, for a total of 30 days.

On or about July 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from June 1, 2022 to June 30, 2022, for a total of 30 days.