Print Violation: 00256742-AP-212162

Provider Information

Magnolia Gardens Senior Living

1425 DAUGHERTY AVE
Cottage Grove, OR 97424

Date: 4/10/2023
Report number: 00256742-AP-212162
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)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) is care planned to have assistance with all ADL’s, including making sure h/h pull up brief is clean and dry. Staff are to assist AV to the bathroom at the start of shift, halfway through and within two hours of end of shift. AV also needs reminders and escort to and from all meals. On or about April 10, 2023, Alleged Perpetrator #2 (AP2) did not check on AV during AP2’s shift or escort AV to breakfast. AV was found on the floor next to h/h bed at approximately 11:20 am wearing a night gown, a wet brief and h/h bedding was soiled with urine. AV was in pain when staff attempted to move h/h. 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.