Print Violation: 00438683-AP-390500

Provider Information

Waterford Grand Memory Care

600 WATERFORD WAY
Eugene, OR 97401

Date: 11/12/2025
Report number: 00438683-AP-390500
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 as a two-person transfer for toileting duties. On or about November 12, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with brief change and did not request another staff to assist. During the process, AV slid from the bed onto the floor. AV didn't suffer any injury, however, AV was placed at risk for harm. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The faciilty's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.