Print Violation: 00194054-AP-155288

Provider Information

Magnolia Gardens Senior Living

1425 DAUGHERTY AVE
Cottage Grove, OR 97424

Date: 4/10/2022
Report number: 00194054-AP-155288
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(a)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) is care planned to have gait belt assistance with all transfers and wear non-skid footwear when transferring. On or about April 10, 2022, Alleged Perpetrator #2 was transferring AV from bed to wheelchair when AV experienced a fall hitting h/h head resulting in a bump on the back of AV head, and AV experienced chest pain. AV was transported to emergency room. 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.