Print Violation: 00217426-AP-176455

Provider Information

Monarch Gardens Memory Care

984 PARKVIEW DRIVE
Brookings, OR 97415

Date: 8/24/2022
Report number: 00217426-AP-176455
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On or about June 1, 2022, the nurse made a note about Alleged Victim (AV) stating he/she had a significant change of condition relating to falls. AV sustained three falls within a week, on May 26th and 28th and on June 1, 2022. AV’s care plan dated July 9, 2022, had the only intervention listed for fall risk was for staff to assist AV when AV is ready to sit. The care plan also stated AV is independent with ambulation and transfers. Between July 17th, through August 16th, 2022, AV sustained approximately eight (8) falls, some resulting in injury and one resulting in an ER visit. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP23-00775 $1500.00 fine assessed