Print Violation: 00412008-AP-363661

Provider Information

Waterford Grand Memory Care

600 WATERFORD WAY
Eugene, OR 97401

Date: 7/3/2025
Report number: 00412008-AP-363661
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(A)
Findings: The Alleged Victim (AV) is a known fall risk and has suffered multiple falls from December 2024 to May 2025. AV had 1:1 supervision during nighttime hours, 10;00 PM to 6:00 AM, to reduce AV's risk of falls. In late May 2025, it was determined AV would have 1:1 supervision between 11:00 PM and 5:00 AM, despite AV's falls typically occurring during the early morning or early evening hours. On or about July 3, 2025, AV suffered a fall leaving his/her room, causing an injury to his/her forehead and a skin tear. AV has a bed alarm; however, it has proven ineffective to reduce AV's falls. The majority of AV's falls have been determined to occur between the hours of 5:00 AM and 7:00 AM, when AV does not have any direct supervision. Respondent failed to ensure staff supervision of AV during times necessary to ensure AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction: RCFCP26-00471 $500.00 fine assessed