Inspection Reports for Monarch Gardens Memory Care
984 Parkview Dr, Brookings, OR 97415, USA, OR, 97415
Back to Facility Profile
Inspection Report
Kitchen
Capacity: 55
Deficiencies: 24
Oct 22, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-04 to 2025-10 with deficiency history and complaint investigations
Findings
Across multiple inspections, the facility exhibited repeated deficiencies related to kitchen sanitation, administration compliance, resident care plans, medication administration, fire and life safety, staff training, and complaint investigations. Several deficiencies were noted as not corrected over multiple visits, with plans of correction documented for each.
Complaint Details
Complaint investigations conducted on 04/04/2023 identified deficiencies related to acuity-based staffing, medications, treatments, and medication administration. One complaint investigation found no deficiencies.
Deficiencies (24)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain a clean and sanitary kitchen with issues including damaged flooring, debris on shelves, spills on refrigerator units, dust on lights, worn cutting boards, and other sanitation concerns |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0000 - Comment: Documented findings of kitchen inspections and compliance with OARs |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate incidents to rule out abuse and report to local SPD office for 2 of 4 sampled residents |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure resident move-in evaluations addressed all required elements for 1 sampled resident |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of resident needs and preferences and implemented for 2 of 4 sampled residents |
| C0270 - Change of Condition and Monitoring: Failed to ensure actions or interventions for changes of condition were documented, communicated, and monitored for 3 of 4 sampled residents |
| C0303 - Systems: Treatment Orders: Failed to ensure medication orders were carried out as prescribed for 2 of 4 sampled residents |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when residents refused consent to medication orders for 2 of 3 sampled residents |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to administration of PRN psychotropic medications for 2 sampled residents |
| C0420 - Fire and Life Safety: Safety: Failed to conduct unannounced fire drills every other month with required documentation and provide fire and life safety instruction on alternate months |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and annually |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure facility was free of unpleasant odors |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors had alarms or acceptable systems to alert staff |
| Z0155 - Staff Training Requirements: Failed to ensure 4 newly hired staff completed required pre-service orientation and dementia training prior to job duties |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to document individualized nutrition and hydration plans based on resident preferences and needs for 4 sampled residents |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for 4 sampled residents |
| Z0168 - Outside Area: Failed to ensure residents had access to enclosed, secured outdoor area without staff assistance |
| C0010 - Licensing Complaint Investigation: Complaint investigation conducted with no deficiencies identified in one instance; other instances noted deficiencies related to compliance |
| C0361 - Acuity-Based Staffing Tool: Deficiencies identified during complaint investigation |
| C0300 - Systems: Medications and Treatments: Deficiencies identified during complaint investigation |
| C0301 - Systems: Medication Administration: Deficiencies identified during complaint investigation |
Report Facts
Inspections on page: 6
Total deficiencies: 29
Total surveys: 6
Licensing violations: 10
Abuse violations: 0
Notices: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KRISTINE SMITH | Administrator | Named as Administrator in facility information and referenced in multiple findings and plans of correction |
| Staff 1 | Executive Director (ED) | Named in multiple inspection findings and interviews acknowledging deficiencies |
| Staff 2 | Facility Services Director / Dietary Director | Referenced in kitchen sanitation findings and plans of correction |
| Staff 3 | Resident Care Coordinator (RCC) | Referenced in multiple findings and plans of correction related to resident care and investigations |
| Staff 4 | Dietary Services Manager (DSM) | Referenced in kitchen sanitation findings and plans of correction |
| Staff 8 | Facilities Services Aide | Referenced in findings related to outdoor area access and exit door alarms |
| Staff 9 | Housekeeping | Named in staff training deficiencies |
| Staff 10 | Caregiver (CG) | Named in staff training deficiencies |
| Staff 11 | Caregiver (CG) | Referenced in change of condition findings |
| Staff 13 | Medication Technician (MT) | Named in staff training deficiencies |
| Staff 14 | Medication Technician (MT) | Referenced in medication administration findings |
| Staff 18 | Cook | Named in staff training deficiencies |
Loading inspection reports...
