Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00314759-AP-267074
Provider Information
Magnolia Gardens Memory Care
1355 DAUGHERTY AVE
Cottage Grove, OR 97424
- Provider ID
- 50R314
- Administrator
- Christina Sexton
- Phone
- (541) 942-8966
- mc.director@magnoliagardenssl.com
Violation Details
- Date
- 2/22/2024
- Report number
- 00314759-AP-267074
- 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)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(A) and (G)
External site: 411-054-0036(2)(g)
- Findings
- Alleged Victim (AV) has history of falls, poor gait, weakness, and poor balance. Interventions for falls have been implemented, including frequent checks and assisting with toileting and brief changes overnight, to prevent AV from getting up independently. Two (2) staff members split the rooms of Alleged Perpetrator 1 (AP1/facility) on NOC shift. On or about February 21, 2024 February 22, 24, Alleged Perpetrator 2 (AP2) was responsible for AV's side. AP2 is tasked with completing frequent checks. At approximately 5:30 am, Witness 4 (W4) found AV on the floor in h/h room with an abrasion to h/h left knee and complaining of pain all over. AV's body and bed were wet. It was discovered that AV had not been checked on since shift change on about February 21, 2024, at approximately 10:00 pm. AP2 told staff s/he had checked on AV around 2:00 am, to ensure AV's needs were met. AP2 should've checked on AV before then, at approximately 12:00 am, and then again around 4:00 am. Per video footage, AP2 was not witnessed checking in on AV at all, either by opening the door and viewing AV, or physically entering the room and checking for wetness. AP2 signed off on checks completed each hour from 10:00 pm to 4:00 am. This information does not align with the statement that one check was done at 2:00am. AP2 understood to check AV every couple of hours. 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.