Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00357275-AP-307611
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
- 9/26/2024
- Report number
- 00357275-AP-307611
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- 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: 411-054-0036(2)(g)
- Findings
- Alleged Victim (AV) has experienced several falls, some with injury. AV is impulsive, with a tendency to not wait for staff to provide assistance. For this reason, AP1 has implemented a pressure alarm. On or about September 26, 2024, AV had an unwitnessed fall and was found on the floor. AP2 did not follow the plan to ensure a response to the pressure alarm going off. Although no injuries were noted at the time of the fall, latent bruising showed up on AV's hands later that day. Staff have been given specific instructions for expectations with the pressure alarm. The pad should be under AV wherever AV is positioned. A staff person is to be carrying the receiver for the alarm at all times and respond as soon as possible. If the person carrying the receiver is unavailable, another staff person should be notified. AP1 had provided all training appropriate to AP2's role, including specific instruction for reading and following service plans and temporary service plans. AP2 did not read the Interim Service Plan. AP2 was given instruction and did understand the requirement to hand off the receiver when going to lunch, AP2 put it in the hub instead. 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.