Print Violation: 00451356-AP-403331

Provider Information

Waterford Grand Memory Care

600 WATERFORD WAY
Eugene, OR 97401

Date: 1/14/2026
Report number: 00451356-AP-403331
Type: Licensing Violation
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)(H)
Findings: On or about January 15, 2026, the Alleged Victim (AV) was wanting to go to the gym. Alleged Perpetrator #2 (AP2) let AV out of the secured unit and did not walk with AV to the gym, rather went to assist another resident. AV walked down the hallway and around a corner, no longer within eyesight of AP2. AV was intercepted by another staff, who observed AV walk into the gym where other residents and staff were participating in an activity. Staff are required to use a walkie talkie to communicate with other coworkers when needed. AP2 did not advise any other staff that AV was let out of the unit by themselves. AP2's actions placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV's safety is a violation of Oregon Administrative Rules.