Waterford Grand Assisted Living

The facility failed to provide appropriate services according to the Alleged Victim's (AV) toileting needs as outlined in his/her care plan which resulted in AV experiencing itchiness in his/her private area causing AV unreasonable and unnecessary discomfort. On or about May 2, 2023, it was discovered that AV's private area was shaved which is not apart of AV's toileting routine. Based on facility documentation and interviews, the facility was unable to determine why AV's private area was shaved, when it occurred, and who did it. Alleged Perpetrator 2 (AP2) is unknown. AP2's failure to follow AV's care plan for toileting caused AV unnecessary discomfort in which AV needed treatment. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to monitor caregivers to ensure caregivers provided appropriate services as outlined in AV's care plan. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and Alleged Perpetrator #2 (AP2) failed to provide appropriate care and services according to Alleged Victim (AV) needs and failed to follow the care plan. AV experiences pain, stiffness and requires extra time when performing ADLs and transferring. AV service plan indicates staff to take AVs complaints of pain seriously, be gentle when touching AV and observe verbal and non-verbal expressions of pain. AV is a one person assist out of bed, allow time to stretch, AV will be stiff at first and will take 10-15 seconds to gain h/h balance. AV may need to get up to use bathroom a couple of times at night. On or about April 15, 2023, AP2 was changing AV in bed and handing AV in a way that caused increased pain in h/h back and legs resulting in unreasonable discomfort AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure to ensure adequate supervision and oversight of AV’s care, is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is high risk for skin breakdown and requires total assistance for toileting and incontinence care which includes applying barrier cream and repositioning after each incontinence care episode. Ongoing instances of AV being found wet, soiled, and unturned have been reported. The facility failed to provide appropriate care and services according to AV needs and failed to follow up on reports of potential abuse to ensure adequate supervision and oversight of AV’s needs, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator #2 (AP2) failed to provide care and services was investigated and the determination was not substantiated.

The Alleged Victim (AV) had a condition which affects the pressure in his/her right eye. AV was prescribed medication for his/her right and left eye. On or about February 26, 2023, the facility received a prescription for AV's right eye to mitigate pressure in AV's eye. The facility has a three-step process to ensure medication orders are processed correctly. On or about June 6, 2024, it was discovered that AV had been receiving his/her eye medication into his/her left eye rather than his/her right eye. When the order was first sent, it was profiled incorrectly by the pharmacy but should have been caught by the facility, as the facility had previous errors with the pharmacy. Alleged Perpetrator #2 (AP2) was the last signatory on the order from February 2023 and did not catch the error. While AV did not have any lasting problems from not receiving the medication, AV could have lost his/her sight from not receiving this medication. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse as outlined in OAR411-020-0002(1)(b)(A)(ii). Respondent failed to ensure staff reviewed medication orders for errors to ensure residents receive proper medication as ordered. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Alleged Victim (AV) relies on the facility for assistance with medications. AV service plan indicates (Same Gender) staff only to apply lotion/powered only to (body region). Approximately during the months of February and March 2023 AV was not provided topical medications by Alleged Perpetrator 2 (AP2) resulting in AV experiencing itchiness, soreness, and unreasonable discomfort. Based on an investigation, it was determined that the facility has no policy regarding applying topical, medications when only opposite gender staff are working, nor is it documented in AV MAR, Care plan or Progress Notes for medication administration when only opposite gender staff are working. The allegation that AP2 failed to administer medications as ordered, was investigated and the determination was not substantiated. The facility failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to administer medication as ordered. Alleged Victim (AV) did not receive h/h medications from approximately April 17, 2022, through April 28, 2022, which resulted in AV needing injections and daily doctors visit for blood work to re-adjust h/h levels, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) requires hands on assistance with transfers and ambulation, and is considered a high fall risk. On or about August 20, 2025, Alleged Perpetrator #2 (AP2) was observed not using AV's gait belt as required. AV was uncomfortable and advised AP2 that it was unsafe. AP2's failure to follow AV's care plan placed AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff follow the care plan is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a volition of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about July 31, 2024, the Alleged Victim (AV) reported he/she was missing money, jewelry and a bowl from his/her apartment. The items were taken by and unknown person, Alleged Perpetrator #2 (AP2). AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about July 31, 2024, the Alleged Victim (AV) reported he/she was missing money, jewelry and a bowl from his/her apartment. The items were taken by and unknown person, Alleged Perpetrator #2 (AP2). AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

According to an investigation, on or about November 25, 2023, Alleged Perpetrator 2 (AP2) handled Alleged Victim (AV) in a rough manner while attempting to redirect him/her from the door, which caused a skin tear and unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility failed to protect a resident from physical abuse which violates Oregon Administrative Rules.

The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse.

The facility failed to administer the resident's medication as order by their physician as required by 411-054-0055(1)(f). Per complainant resident received eye medication to left eye and should have been to right eye, which is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide a safe medication administration system for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

On or about December 01, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days

The facility failed to carry out medication and treatment orders as prescribed resulting in the resident receiving their medications as scheduled at 7:50pm and another staff administering resident's meds a second time at 8:20pm, which is a violation of Oregon Administrative Rules.

On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim's (AV) medications were administered as ordered. It was discovered AV’s medications were given “late” due to AV not being in h/h room, and the facility not having AV medications available to administer, placing him/her at risk of harm, hallucinations, and emotional upset, which is a violation of Oregon Administrative Rules.

The facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident resulting in the facility not having incident reports filled out after multiple falls, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV requires a two person assist with Hoyer lift for transfers. On or about October 22, 2021 Alleged Perpetrator #2 (AP2) used the Hoyer lift to transfer AV from Bed to wheelchair. AP2 placed the Hoyer sling under AV incorrectly, so when AV was placed onto his/her wheelchair he/she slid down toward to the floor. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.