Print Violation: 00405141-AP-356130

Provider Information

Magnolia Gardens Memory Care

1355 DAUGHERTY AVE
Cottage Grove, OR 97424

Date: 6/1/2025
Report number: 00405141-AP-356130
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(g) and (s)
411-054-0030(1)(e)(G)
411-054-0036(2)(g)
Findings: On June 1, 2025, around 12:00 a.m., Alleged Victim (AV) was found on the floor beside the bed with urine-soaked clothing and bedding. AV was a known high fall risk and care-planned to be checked and toileted at least four times per shift. Alleged Perpetrator 2 (AP2) was assigned to be AV's caregiver during the overnight shift beginning at 10:00 p.m. on May 31, 2025, and AP2 was informed AV was last toileted at 8:30 p.m. There is no documentation or footage showing AP2 toileted AV before the fall. AP2 had prior disciplinary actions for inadequate resident care and toileting. By failing to follow AV’s toileting care plan, AP2 left AV to attempt self-transfer to toilet, resulting in a fall and unreasonable discomfort. AP2’s actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.