Magnolia Gardens Senior Living

Last inspection

February 4, 2026

Inspections

7, 24 deficiencies cited

Substantiated abuse

15

Substantiated licensing violations

27

Regulatory actions

0

Fines assessed

$8,375.00 (15 violations)

Current owner since

August 1, 2025

Inspections

• February 4, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• March 22, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• May 24, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• January 10, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
• December 5, 2022: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• November 2, 2022: Complaint Investig., 6 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0241: Resident Services: Laundry severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Isolated
• February 14, 2022: Validation, 13 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected September 4, 2022
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected September 4, 2022
  Show all 18

  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected May 30, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected September 4, 2022
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected May 30, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected May 30, 2022
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected May 30, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected May 30, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected May 30, 2022
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected September 4, 2022
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected May 30, 2022
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected May 30, 2022

Substantiated abuse or neglect

• September 12, 2025: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to provide necessary care and services as required by the Alleged Victim’s (AV) care plan and assessed needs. Based on facility documentation and interviews, AV had an active wound on the right foot under his/her big toe and was receiving home health services until discharge on 9/8/25, at which time the wound was nearly healed. On 9/10/25, 9/13/25, and 9/17/25, facility staff did not assess or observe AV’s wound, despite AV’s care needs and the requirement to provide ongoing wound monitoring. Staff relied solely on the presence of clean, dry, intact bandages applied by AV’s medical provider on 9/12/25 and failed to assess the underlying wound. Failure to provide required monitoring and nursing oversight resulted in deterioration of AV’s wound, causing unreasonable discomfort, pain, and physical harm, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• July 27, 2024: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility (AP1) manages all aspects of Alleged Victim's (AV's) medication management, including ordering and storing, and administration except for temporary use of a PRN narcotic pain reliever to be used after a recent surgery. AV is prescribed several medications including an antiarrhythmic, beta-blocker, anti depressant, acid-reducer, and anticoagulant. AV missed doses of each of these medications because AP1 staff did not have them available for AV. AV's medications are sent from the pharmacy in a cycle-fill. This means that staff responsible for ordering medications do not assume they need to manually reorder. Sometimes the pharmacy will need more information or documentation before the cycle-fill can be completed. This is typically communicated throughout checks and verifications completed weeks in advance. AV's provider was faxed for a new prescription only after AV had already missed doses of medication. AV missed multiple doses of multiple medications before this incident was corrected, which led to AV reporting to multiple people that AV was feeling unwell. On or about July 30, 2024, AV told staff that AV had tightness in h/h chest and nausea, and approximately on July 31, 2024, AV had a higher than typical blood pressure reading. AV has symptoms of head hurting and feeling restless, like s/he can't stop moving or talking. AV feels like s/he is having withdrawals from missing two consecutive days of h/h antidepressant. The facility failed to have adequate supply of AV medications and provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 2, 2024: Failed to administer medication as ordered Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) self-administers some medication but will have all medication ordered through AP1's pharmacy. AP1 staff are instructed to reorder medication within seven days of last dose availability. In March 2024, AP1 staff failed to reorder AV's PRN medication for breathing in a timely manner. AV's medication was typically only used two times a day, staff collectively failed to place a reorder request until March 8, 2024. When the reorder was placed, additional pharmacy follow-up was required. AV had begun using the medication more frequently, and AV ran out of medication completely. Every staff person working on the medication cart is responsible for ordering medications and following up timely with requests. However, AP1 had multiple staff working on the cart who did not have pharmacy log-in capabilities. AV running out of h/h medication resulted in a visit to the emergency room (ER) for shortness of breath. AP1's training is clear that refills must be reordered before medication reaches a 7-day supply, however due to a collective facility failure to follow this protocol, AV ran out of medication and experienced an increase in shortness of breath resulting in a visit to the ER for shortness of breath, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 8, 2023: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) is incontinent, has a history of chronic UTI’s and is care planned for brief changes and peri-care on each shift. During brief changes staff are to clean the skin in the groin, thighs and apply barrier cream if the skin is red. Brief changes are marked with date and time of each change. MAR indicates a barrier cream is prescribed as PRN to be applied topically to affected areas with a start date of October 31, 2022. On or about March 08, 2023, AV was brought into the Emergency room, wearing a brief with a date of March 05, 2023. AV was found to be bleeding out of h/h genitalia from a rash, had a UTI and was in pain. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 5, 2022: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) is a high fall risk and is care planned for assistance with ambulation. On or about November 05, 2022, AV was walking unassisted and fell resulting in a fractured hip. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Substantiated licensing violations

• April 10, 2023: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s 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.

• January 19, 2023: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about December 21, 2022, AV had a fall while being transferred by Alleged Perpetrator #2 (AP2). AV is care planned to use a gait belt for transfers. AP2 was not using a gait belt when attempting to transfer AV. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

• December 30, 2022: Failed to provide infection control Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0050 (Infection Prevention and Control)
  State’s findings

  The facility failed to comply with masking requirements, resulting in masks not being regularly worn by staff, and when they are worn, mask are usually down around the neck. Visitors are often seen without masks also exposing residents to potential harm, which is a violation of Oregon Administrative Rules.

• December 5, 2022: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules.

• December 5, 2022: Failed to provide infection control Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. An investigation determined this is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 73 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.