Print Violation: 00266910-AP-221834

Provider Information

Waterford Grand Assisted Living

600 WATERFORD WAY
Eugene, OR 97401

Date: 6/2/2023
Report number: 00266910-AP-221834
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings: The facility failed to provide a safe medication administration system for Alleged Victim (AV). On or about June 2, 2023, the facility discovered that AV's liquid pain medication was not the right color. Instead of appearing bright blue, AV's liquid pain medication was a gray color and appeared a different texture. Based on facility documentation and interviews, it was determined that the facility failed to monitor that medication aides completed their job duties correctly to ensure accurate narcotic counts. The facility's failure put AV at risk of harm to receive medications that were tampered with which is a violation of resident rights, is considered neglect of care, and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined inconclusive findings.
Sanction: ALFCP23-00687 $375.00 fine assessed