Waterford Grand Memory Care

On or about February 28, 2025, the Alleged Victim (AV) exited the secure facility from an exterior courtyard door. There had recently been a fire drill, and the exterior door mechanism malfunctioned. All doors are to be checked after a fire drill by staff, and while doors were checked, the exterior door was not checked, and AV exited from this door. AV is a fall risk, and leaving the facility without supervision placed AV at risk for harm.

The Alleged Victim (AV) is a known fall risk and suffered multiple falls between October 2024 and January 2025. Although AV did not suffer injuries from these falls, AV was placed at risk of serious harm from the falls. The facility's failure to ensure AV's safety from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 18, 2025, the Alleged Victim (AV) was discharged from hospice care, without a confirmed care plan or continuity of his/her opioid prescription. AV missed 8 doses of his/her opioid medication from January 24, 2025, and January 28, 2025, leaving AV with increased pain and agitation, causing increased falls due to unmanaged pain. The facility's failure to manage AV's medications is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has care needs that include a specific dental diagnosis that requires daily, consistent care. AV's care plan regarding the oral care was vague and missing two of the steps necessary to ensure AV's oral hygiene. AV was found frequently to have remains of food around his/her gum line, heavy plaque buildup and stained teeth. The facility's failure to ensure proper oral hygiene placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to be physically aggressive towards staff and residents. On or about July 5, 2024, W1 entered the Alleged Victim's (AV) room and pushed AV out of his/her bed. AV was not physically harmed, however, AV was scared and suffered emotional harm. The facility failed to implement interventions to ensure the safety of AV. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has multiple interventions in place. Despite the interventions, AV continues to have falls with and without injury. Staff are to ensure AV is to have proper footwear on, is to use his/her walker, and has increased safety checks. The facility is not ensuring that staff are implementing the interventions, and AV continues to have falls at the facility, including a fall where AV suffered a head injury requiring stitches to his/her head. Staff seem to be unaware of the interventions in place for AV. The facility's failure to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) used to use a walker and changed to using a wheelchair. AV is care planned to use a walker with assistance and reminders, and the care plan does not mention a wheelchair. AV has a history of falling from the wheelchair. On or about October 23, 2024, AV stood up from his/her wheelchair and fell. There was no clear direction to staff in the care plan, as the care plan was not updated. The care plan was not updated when AV had a change of condition in his/her ability to ambulate with a walker to changing to a wheelchair. The facility's failure to ensure proper care planning and have oversight to a change of condition is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement/follow appropriate interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On May 14, 2023, AV suffered a fall and was found on the floor. A fall intervention was put into place on May 18, 2023, to lower AV's bed as low as it will go to prevent AV from falling during transfers, etc. However, on June 14, 2023, AV's bed was observed to not yet be lowered placing AV at risk for falls. As a result of facility failing to properly care plan for AV's fall risk, AV was placed at continued risk of harm which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide adequate supervision to Alleged Victim (AV), which resulted in AV suffering multiple falls with injuries while self-propelling in his/her wheelchair. Based on facility documentation and interviews, at time of investigation AV's care plan did not reflect AV's current care needs related to ambulation which placed AV a risk of more falls. The facility's failure to properly care plan for AV's fall risk is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services and a safe environment according to the Alleged Victim’s (AV’s) needs. AV has a history of banging on tables and resident-to-resident altercations in the dining area with Witness #1 (W1). Care plan directs staff to seat AV away from stable or object that s/he can bang on. AV and W1 have TSP to monitor interactions between residents to interevent, redirect, and separate when possible. On or about April 29, 2023, AV and W1 were placed back-to-back in dining room. AV began banging on a table, W1 reported to staff it bothered h/h, AV was given water to keep AV hands busy. AV continued to bang on table, W1 wandered over to AV and put h/h hands around AV neck placing AV at risk of serious harm. The facility’s failure is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. AV service plan indicates AV is a one-person assist with transfer using a gait belt, and staff to provide 3-4 safety checks per shift. On or about January 19, 2023, AV bed alarm triggered call light at 5:21am during NOC shift and was not answered for 2 hours and 10 minutes. When day staff responded AV was found on h/h couch having transferred without assistance. Later in the morning AV was found to have bruising on h/h nose and under h/h eyes. The Facility failed to provide a safe environment and failed to answer AV call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow the care plan. Alleged Victim (AV) service plan indicates to use mechanical lift for all transfers. Two person Hoyer assist for all transfers. On or about September 11, 2022, agency staff attempted to transfer AV out of bed by stand by assist, resulting in AV slipping from the bed to the floor. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan regarding Witness 1 (W1) negative behaviors towards staff and other residents. W1 and Alleged Victim (AV) have a history of resident-to-resident altercations. On or about September 06, 2022, W1 took AV in h/h wheelchair and rammed AV into a living room chair, resulting in bruising to AV legs. The facility failed to adjust and provided interventions appropriate to mitigate W1 continued aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of agitation and aggression towards other residents and members of the care team. W1 had approximately three (3) incidents of violence and aggression from August 14, 2022, to August 29, 2022. On or about August 30, 2022, W1 pushed AV’s wheelchair and punched AV in the stomach. The facility failed to appropriately adjust W1 care plan and implement reasonable interventions to address continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. The AV service plan indicates AV can transfer on h/h own, staff are to stand by for assistance, staff are to perform routine checks at mealtimes and hours of sleep. On or about August 26, 2022, AV was checked on at approximately 6:00am. AV was not checked on again until approximately 11:05am when staff found AV on the ground. The facility failed to check on AV at the frequent scheduled intervals and failed to provide adequate supervision and care to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) had approximately Nine (9) falls from approximately May 03, 2022, to August 14, 2022. AV was diagnosed with, skin tears, abrasions, and bruises. Interventions put in place after falls were unchanged from previous interventions, were not person-specific and were generic in nature. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls. On or about July 15, 2022, AV had an un-witnessed fall and was found on the floor, resulting in a nasal fracture. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and is care planned for two-person assist. On or about July 10, 202, it was reported Witness 4 (W4) attempted to transfer AV alone and AV slid off the edge of the bed. AV did not sustain injury. The facility failed to follow AVs care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The facility failed to follow the care plan. Alleged Victim (AV) is care planned to use a wheelchair for all ambulation, and a two-person transfer with a gait belt. On or about, June 07, 2022, AV experienced a fall when standing on a bus lift with h/h walker. AV reported left side ache and sustained a skin tear to left finger. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and is care planned for a bed alarm, and Non-skid socks. On or about March May 05, 2022, AV was found on the floor, resulting in AV hitting head and being sent to the emergency room. AV’s bed alarm did not go off as it was not attached and, AV was not wearing Non-skid socks. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and is care planned for a bed alarm, and Non-skid socks. On or about March May 01, 2022, AV was found on the floor, resulting in AV having knee pain. AV’s bed alarm did not go off as it was not attached and, AV was not wearing Non-skid socks. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is a high fall risk and is care planned for Adhesive strips applied to shower floor for safety. On or about April 29, 2022, AV slipped in the shower causing a small abrasion. The facility failed to follow AVs care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned for a fall mat, and a pool noodle to keep AV from rolling out of bed. On or about April 27, 2022, AV was found on the floor next to bed in the fetal position. AV’s fall mat and pool noodle were not in place. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, including lack of appropriate interventions which include safety checks, and AV's known unreliable use of the call system. AV experienced approximately six (6) unwitnessed injury and non-injury falls in the month of April 2022. AV injuries included broken finger, re-open of prior skin tear, abrasions to knees, and laceration to scalp. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls. On or about March 31, 2022, AV had an unwitnessed fall and was found on the floor. AV sustained abrasions and a skin tear. AV had a bed alarm to alert staff when AV is trying to get out of bed. It was discovered the care plan does not reflect the use of a bed alarm or re-setting the bed alarm after it has been set off. The facility failed to appropriately care plan, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to have service plans reflective of the resident's needs as identified in the evaluation and have service plans reflect the resident’s needs as identified in the evaluation and include a written description of who shall provide the services and what, when, how, and how often the services shall be provided in accordance with OAR 411-054-0036(2); per a report that resident's service plan did not reflect their fall history and interventions needed. The failure is a violation of Oregon Administrative Rules.

The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility failed to update an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(4)(c), which is a violation of Oregon Administrative Rules.

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.

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.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2)(b), which is a violation of Oregon Administrative Rules.

The facility failed to ensure the service plan must reflect the resident's needs in accordance with OAR 411-054-0036(2); per complaint the facility has not service planned for memory care residents relationships, which is a violation of Oregon Administrative Rules.

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.

The facility failed to carry out medication and treatment orders as prescribed per complaint resident received the wrong dosage of their Sertraline on multiple occasions, which is a violation of Oregon Administrative Rules.

On or about April 7, 2024, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with toileting. During this interaction, AV started to bite at staff. AP2 put his/her finger in AV's mouth and pushed down, causing AV to say "ow", and told AV that AP2 is stronger than him/her. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2) failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AVs service plan indicates one person assist with transfers and allow AV to transfer at h/h own speed. Investigation indicates on or about April 25, 2023, AV required toileting assistance, and AP2 was assisting AV with transfer. AV reports AP2 was pulling on h/h arm causing pain, and AV verbally and repeatedly asked AP2 to stop. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to ensure AV received appropriate services and care which is a violation or Oregon Administrative rules.

The Alleged Victim (AV) charging cord went missing from his/her room. The items were taken by Alleged Perpetrator #2 (AP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to follow the Alleged Victim's (AV) care plan to ensure s/he does not receive plastic silverware with meals due to a history of chewing and ingesting them. On or about April 14, 2023, AP2 gave AV breakfast with a plastic spoon, which was later discovered be partially missing causing AV to be transferred to the hospital for assessment. AP2's failure placed AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to assure AV's safety, which is a violation of Oregon Administrative Rules.

On or about March 16, 2022, AV had a fall while being transferred by Alleged Perpetrator #2 (AP2). AV is care planned to be a two-person assist with transfers. AP2 attempted to transfer AV without a second person to assist causing AV to fall during the transfer attempt. 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.