Print Violation: 00356125-AP-306531

Provider Information

Hawthorne Gardens Memory Care Community

2828 SE TAYLOR ST
Portland, OR 97214

Date: 9/21/2024
Report number: 00356125-AP-306531
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(s)
External site: 411-057-0170(1)
Findings: The Alleged Victim (AV) resides in a secured memory care unit and relies on the facility for his/her care. AV has a history of exit seeking behaviors and falls. Care planned behavior interventions were that AV required staff to provide redirection. The memory care unit has an elevator, and the door opens into the secured unit common area. According to an investigation, on or about September 21, 2024, AV entered the elevator without staff assistance. AV exited the elevator in an unsecured area of the building and fell down a stairwell, resulting in hospitalization and a fractured back. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.
Sanction: RCFCP24-01168 $500.00 fine assessed