Print Violation: 00373523-AP-323895

Provider Information

Waterford Grand Memory Care

600 WATERFORD WAY
Eugene, OR 97401

Date: 12/22/2024
Report number: 00373523-AP-323895
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)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) is care planned to be transferred using a lift. On or about December 22, 2024, Alleged Perpetrator #2 (AP2) transferred AV without using the lift, but rather by utilizing a bear hug to move AV from his/her bed to his/her wheelchair. During this transfer, AV sustained a skin tear, which likely would not have happened had the care plan been followed and AV was transferred as care planned. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was being followed is a violation of Oregon Administrative Rules.