Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00462267-AP-414578
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
- 3/8/2026
- Report number
- 00462267-AP-414578
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
- Findings
- The facility failed to implement appropriate interventions and provide adequate supervision despite the Alleged Victim’s (AV) known history of falls. As a result, AV experienced multiple unwitnessed falls that caused unnecessary and unreasonable discomfort. AV resided at the Respondent's facility during the relevant period. Facility documentation and interviews show that between January 20, 2026, and March 6, 2026, AV experienced ten non-injury falls. Two of those falls included reports of pain. In addition to the ten non-injury falls, AV sustained three additional falls that resulted in injury. On February 10, 2026, AV fell in the facility’s common area. Video footage shows AV striking their head on the floor; however, the facility did not send AV for medical evaluation following the incident. On March 7, 2026, AV suffered another fall in which AV was found on the floor in the dining room with AV's head bleeding at around 10pm. Based on facility documentation and interviews, AV fell out of a chair in the dining room while trying to hold onto it, hitting AV’s head and shoulder on the floor. As a result of this fall, AV experienced unreasonable discomfort. The facility did not develop or implement adequate interventions to mitigate AV’s known fall risks due to AV continuing to fall with injury which resulted in repeated falls and unnecessary and unreasonable discomfort. The facility's failure to appropriately care plan for AV's known fall risk is a violation of resident rights, is considered of neglect of care which constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00571 $375.00 fine assessed