Print Violation: 00189551-AP-151351

Provider Information

Waterford Grand Memory Care

600 WATERFORD WAY
Eugene, OR 97401

Date: 3/16/2022
Report number: 00189551-AP-151351
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings: On or about March 16, 2022, AV had a fall while being transferred by Alleged Perpetrator #2 (AP2). AV is care planned to be a two-person assist with transfers. AP2 attempted to transfer AV without a second person to assist causing AV to fall during the transfer attempt. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.