Print Violation: 00330935-AP-282212

Provider Information

Monarch Gardens Memory Care

984 PARKVIEW DRIVE
Brookings, OR 97415

Date: 5/12/2024
Report number: 00330935-AP-282212
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: Alleged Victim (AV) is care planned to be on a pureed diet only. On or about May 12, 2024, Alleged Perpetrator 2 (AP2) gave Jello to AV which contained fruit chunks to AV. As a result, AV began to choke on a piece of fruit and was given the Heimlich to expel the chunk of fruit he/she was choking on. AP2 failed to follow the care plan around AV’s pureed diet, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was being followed, which is a violation of Oregon Administrative Rules.