Print Violation: 00355737-AP-306470

Provider Information

Hawthorne Gardens Senior Living Community

2828 SE TAYLOR ST
Portland, OR 97214

Date: 8/21/2024
Report number: 00355737-AP-306470
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide oversight and monitoring of change of condition
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025 (1)(a) and (b)
External site: 411-054-0027 (1)(g) and (s)
External site: 411-054-0028 (2)
External site: 411-054-0040 (1)(b)(c)(2)(a)
External site: 411-054-0055 (1)(a) and (f)
Findings: The Alleged Victim (AV) relies on the facility to assist with activities of daily living. According to an investigation, on or about August 11, 2024, the AV was placed on alert charting related to a pressure ulcer on the right foot. Wound care instructions left by a medical provider were not implemented. A change in the condition of the AV's lower right extremity, including swelling, redness, and being hot to the touch, were not monitored or documented. The AV was admitted to the hospital and presented with sepsis secondary to right lower extremity cellulitis. The facility failed to implement wound care as ordered and to monitor the AV's changes in condition, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction: ALFCP25-01029 $500.00 fine assessed