Hawthorne Gardens Senior Living Community

    2828 SE Taylor St, Portland, OR 97214
    • Assisted Living
    • Memory Care
    4.1·71 reviews
    For the front desk(971) 222-0396

    Attentive staff, beautiful safe community

    I moved my mom here and have been very pleased. The setting is beautiful and residential, with a small, intimate community that feels homey. Staff from admissions to caregivers are outstanding-attentive, responsive, and genuinely caring-and the meals are excellent with good variety. The building is clean and safe, activities are plentiful, transportation is included, and move-in was smooth; I would recommend it.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Transportation arrangement (medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Dining room
    • Garden
    • Outdoor space
    • Small library

    Community services

    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.14·(71)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1

    • Care

      3.7

    • Staff

      4.1

    • Meals

      3.4

    • Amenities

      3.6

    • Value

      3.0

    Pros

    • Compassionate, respectful caregiving staff
    • Warm and welcoming front-desk reception
    • Home-like, intimate community atmosphere
    • Attractive, well-maintained common areas
    • Neighborhood setting with walkable grounds
    • Private, light-filled apartment options
    • Secure memory-care safety features
    • Engaged culinary team with improved menus
    • On-site transportation services included
    • Varied activity programming and community outings
    • Responsive administrative communication under new leadership
    • Accessible outdoor amenities and garden spaces
    • Quick, accommodating move-in and tour process
    • Technology and IT support for residents
    • Engaged unit-level staff with long-tenure caregivers

    Cons

    • Inconsistent staffing levels, especially in memory care
    • High staff turnover and gaps in dementia-care training
    • Cleanliness and sanitation issues in some rooms and units
    • Incontinence-care delays and localized odor concerns
    • Medication-management and reconciliation inconsistencies
    • Variable meal quality and inconsistent dietary accommodations
    • Irregular activity coverage and programming consistency
    • Leadership instability and uneven communication during transitions
    • Laundry, personal-belongings, and inventory-control problems
    • Elevated monthly costs and concerns about future rate increases
    • Accessibility bottlenecks (single small elevator, crowded dining)
    • Scheduling and transportation coordination challenges

    Summary of reviews

    Overview Hawthorne Gardens elicits a mixed but informative set of impressions. Many families and residents praise the facility’s warm, neighborhood feel, personable front-desk reception, attractive common spaces and outdoor areas, and private, light-filled rooms. At the same time, recurring operational themes — particularly around staffing consistency, cleanliness in select units, and management turnover — appear frequently enough to be material factors for prospective families to weigh.

    Care and staff Across reviews there is a clear appreciation for individual caregivers who are described as compassionate, respectful, and familiar with residents by name. Long-tenured caregivers and engaged unit-level staff are cited as strong points. However, reviewers also describe inconsistent staffing levels (notably on the memory-care unit), high turnover, and gaps in dementia-focused training. Those operational weaknesses are linked in several accounts to delays in assistance, variability in how personal-care tasks are handled, and inconsistent clinical follow-through. There are also multiple notes about medication-management and reconciliation issues; families should ask about current med-administration protocols and recent staffing ratios when evaluating the community.

    Dining and dietary accommodations Dining impressions are mixed but dynamic. Several recent comments praise an engaged culinary team, thoughtfully created menus, and improved plating and ingredient quality after leadership and chef changes. Conversely, other accounts describe episodes of unappealing or inconsistent meal quality and difficulties obtaining specialized dietary accommodations or clear menu labeling (for example, gluten-free or dairy-free options and cross-contamination controls). Prospective residents who have strict dietary needs should request current menus, sample meals, and a description of dietitian involvement and cross-contact procedures.

    Activities and social programming Many reviewers highlight active programming, daily activities, outings with photo documentation, and a supportive activities director — especially when that role is staffed and stable. Yet activity coverage is reported as uneven at times; weekends and periods of understaffing may result in reduced offerings and increased TV time for residents. Prospective families should inquire about the current activity calendar, staff-to-activity ratios, and backup coverage plans for staff absences.

    Facilities, housekeeping, and logistics The building, grounds, and common areas are often described as attractive and home-like, with good outdoor amenities and neighborhood walkability. Safety features for memory care, such as controlled access, are commonly noted. Nonetheless, several reviews point to cleanliness and sanitation issues in particular rooms or units, laundry and personal-belongings management problems, and periodic odor concerns — operational areas that indicate variability in housekeeping and incontinence-care follow-through. Accessibility considerations mentioned by reviewers include a single small elevator that can create delays and crowded dining during peak times.

    Management, communication, and patterns over time A prominent theme is change over time. Multiple reviewers described improvements after new administrative hires and operational focus (improved communication, chef-driven menu changes, restored housekeeping, and increased staffing). Others describe prior or intermittent periods of weakened oversight, higher rates, and service declines. This suggests the facility’s performance can be sensitive to leadership and staffing stability. Families should ask about recent leadership tenure, turnover rates, current staffing ratios (especially in memory care), and any planned sales or rate increases.

    What to watch and ask about When considering Hawthorne Gardens, prospective residents and families may want to: review recent staffing ratios and turnover metrics; confirm current housekeeping and laundry protocols; request current menus and dietary-accommodation procedures; ask for the activity schedule and backup coverage plans; verify medication-management processes and reconciliation procedures; and discuss cost increases and contract terms. Many reviewers praised individual staff and community strengths, but the operational variability highlighted in these accounts makes targeted questions and an up-to-date tour especially important.

    Bottom line Hawthorne Gardens combines several genuine strengths — compassionate caregivers, an intimate neighborhood setting, attractive spaces, and an engaged culinary and activities staff when those roles are stable — with operational vulnerabilities tied to staffing consistency, housekeeping, and management transitions. The community may be a strong fit for families who prioritize a small, home-like environment but who also perform due diligence on current staffing, clinical processes, and housekeeping standards before committing.

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    Location

    Map showing location of Hawthorne Gardens Senior Living Community

    Hawthorne Gardens Senior Living Community is located at 2828 SE Taylor St, Portland, OR, 97214.

    About Hawthorne Gardens Senior Living Community

    Hawthorne Gardens Senior Living Community sits in a quiet, residential part of Portland's scenic Willamette Valley, offering a peaceful place for seniors while still being close to city life. The building is three stories tall with large windows and soft Pacific Northwest colors, and has cozy spaces decorated to feel warm, inviting, and a little elegant without being fussy. There are several types of apartments, including studios and one-bedroom suites, all designed so they feel like home, and folks here can bring pets since the place is pet-friendly.

    Residents must be at least 63 and have a choice of independent living, assisted living, skilled nursing, respite care, and memory care, so people can stay here while their needs change instead of moving somewhere else. The memory care program supports people living with memory loss, dementia, or Alzheimer's, focusing on safety, routines, and specialized activities for the mind, and it has a secure environment with staff who know what they're doing, in a separate but nurturing part of the community. For those in assisted living, there's daily help available, like bathing, dressing, grooming, medication management, and reminders, with care plans shaped around each person and plenty of staff present 24/7. Respite care is also available for short stays when caregivers need time off or someone just needs temporary extra help.

    Housekeeping, laundry, and linen service come once a week in the base rent, with added support for personal care, incontinence, and escorting folks to activities or meals as needed. There's free Wi-Fi for residents and good parking options including covered spots, plus complimentary and fee-based transportation for outings, medical visits, and activities around Portland, and the property's near bus lines if someone wants to be independent.

    There's always a full calendar of activities, with group events like shopping trips, crafts, socials, and devotional services either on-site or close by. There's a piano, an organ, raised gardening beds, outdoor courtyards, and a TV lounge for people to relax or visit with friends and family, and staff encourage new friendships through all sorts of social opportunities. The dining room feels lively at mealtimes, with nutritious, chef-prepared meals served restaurant-style, a private dining area for family gatherings, guest meal options, and they cater for special diets like gluten-free.

    Common areas include a beauty salon, fireplaces, open lounges, and both indoor and outdoor space for gatherings. Everything is designed with comfort and safety in mind, including wheelchair accessible showers and plenty of space to move around. Hawthorne Gardens has a reputation for helpful, upbeat staff, with awards for kindness, active engagement, and the overall caring atmosphere-folks can even follow the community on social media if they want, since the community's got Facebook and Instagram. Care teams are easy to find at any time, so residents get help when they need it, and the community puts a lot of focus on independence, dignity, and creating a real sense of belonging, so people feel at home even as their care needs change. Tours are available for those who want to see what life is like at Hawthorne Gardens and the staff use a "Get Acquainted Visit" to make sure new residents get the right support.

    People often ask...

    Hawthorne Gardens Senior Living Community offers competitive pricing, with rates starting at a cost of $4,427 per month.

    Hawthorne Gardens Senior Living Community offers assisted living and memory care.

    There are 44 photos of Hawthorne Gardens Senior Living Community on Mirador.

    The full address for this community is 2828 SE Taylor St, Portland, OR 97214.

    No, Hawthorne Gardens Senior Living Community does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number50R350
    StatusActive
    Facility typeResidential Care Facility
    Capacity35 residents
    LicenseeSsa Oregon, LLC
    EffectiveJuly 30th, 2007
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    152

    Reports

    0

    Type A Citations

    0

    Type B Citations

    3

    Complaints

    16

    Years

    22 Dec 2025Inspection
    Investigated the allegation and found that service plans did not reflect residents' needs or include preferences that support dignity, privacy, choice, individuality, and independence.
    • Licensing—Failed to properly plan care
    22 Dec 2025Inspection
    Investigated an allegation of inadequate oversight and monitoring of changes in condition and identified a violation of Change of Conditions and Monitoring requirements.
    • Licensing—Failed to provide oversight and monitoring of change of condition
    18 Dec 2025Kitchen
    Found deficiencies in kitchen sanitation, with extensive cleaning and hygiene issues observed.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    18 Dec 2025Kitchen
    Identified deficiencies in food sanitation practices and administration compliance. Observations showed unsanitary kitchen conditions and failures to follow licensing rules.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    13 Dec 2025Inspection
    Investigated a violation regarding safe medication administration practices and found that medications were left unattended, placing a resident at risk.
    • Licensing—Failed to provide a safe medication administration system
    11 Aug 2025License Condition
    Determined non-compliance with safety requirements. The non-compliance posed a threat to residents' health, safety, and welfare.
    • Regulatory Action—Failed to provide safe environment
    11 Jul 2025License Condition
    Determined the provider was not in substantial compliance and posed a threat to residents' health, safety, and welfare.
    • Regulatory Action—Failed to provide safe environment
    04 Jul 2025Abuse: Neglect
    Investigated an abuse and neglect allegation and identified safety and care planning deficiencies that risked resident safety.
    • Abuse—Failed to address resident's behavior
    13 Jun 2025Change of Owner
    Multiple deficiencies found in abuse reporting, resident move-in evaluations, service planning, condition monitoring, health services, medication systems, staffing, ABST updates, training, fire safety, building maintenance, plumbing temps, call systems, resident choice, and move-in documentation.
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Move-in & Evaluation: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Resident Right to Refuse
    • Deficiency—Systems: Medication Administration
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity Based Staffing Tool - ABST Time
    • Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
    • Deficiency—Staffing Requirements and Training – Pre-service
    • Deficiency—Training Within 30 Days of Hire – Direct Care Staff
    • Deficiency—Annual and Biennial Inservice for All Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training for Residents
    • Deficiency—General Building Exterior
    • Deficiency—General Building: Doors-Walls, Cleanable
    • Deficiency—Plumbing Systems
    • Deficiency—Call System
    • Deficiency—Individual Choice Setting Services&Support
    • Deficiency—Resident Move-in & Evaluation: Res Evaluation
    11 Jun 2025Change of Owner
    Identified widespread deficiencies across governance, resident care, safety, and staffing with evident oversight gaps and multiple rule violations.
    • Deficiency—Facility Administration: Operation
    • Deficiency—Facility Administration: Required Postings
    • Deficiency—Facility Administration: Quality Improvement
    • Deficiency—Reasonable Precautions
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Move-in & Evaluation: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—RN Delegation and Teaching
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication Administration
    • Deficiency—Training Within 30 Days of Hire – Direct Care Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training for Residents
    • Deficiency—Emergency and Disaster Planning
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building Exterior
    • Deficiency—Doors, Walls, Elevators, Odors
    • Deficiency—Individual Privacy: Own Unit
    • Deficiency—Individual Door Locks: Key Access
    • Deficiency—Facility Administration: Required Postings
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance with Rules Health Care
    • Deficiency—Nutrition and Hydration
    • Deficiency—Outside Area
    • Deficiency—Secure Outdoor Recreation Area
    02 Apr 2025Complaint
    Investigated a licensing complaint and identified deficiencies with regulatory compliance.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Acuity Based Staffing Tool - Abst Time
    31 Mar 2025Abuse: Neglect
    Investigated an abuse and neglect allegation and found insufficient oversight of changes in condition during transfers, leading to injuries and failure to monitor or respond.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    18 Feb 2025Abuse: Neglect
    Investigated an allegation of neglect and abuse and found a failure to provide a safe environment, resulting in injury to a resident.
    • Abuse—Failed to provide safe environment
    12 Nov 2024Kitchen
    Identified multiple deficiencies in kitchen sanitation and administration compliance. Observed numerous unsanitary conditions and failure to follow licensing rules.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    12 Nov 2024Kitchen
    Identified extensive kitchen sanitation and food storage deficiencies, including debris, improper storage, and inadequate hygiene practices.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    03 Oct 2024License Condition
    Found that acts/omissions created a risk of immediate jeopardy by failing to provide a safe environment.
    • Regulatory Action—Failed to provide safe environment
    21 Sept 2024Abuse: Neglect
    Investigated and found a failure to provide a safe environment that constitutes abuse and neglect.
    • Abuse—Failed to provide safe environment
    21 Aug 2024Abuse: Neglect
    Found neglect and abuse due to failure to monitor a resident's condition and to implement wound care, leading to hospitalization for sepsis.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    05 Jul 2024Abuse: Neglect
    Investigated a complaint and found cough medication was not given on time as ordered, causing discomfort and indicating neglect/abuse; a fine was assessed.
    • Abuse—Failed to administer medication as ordered
    04 Apr 2024Inspection
    Found that the entity failed to fully implement and update an acuity-based staffing tool, violating Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    01 Apr 2024Complaint
    Investigated and found deficiencies across records retention, resident meals and food safety, service plan implementation, infection prevention, medication management, staffing, and staff training.
    • Deficiency—Facility Administration: Records
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Service Plan: General
    • Deficiency—Infection Prevention & Control
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Annual and Biennial Inservice For All Staff
    01 Apr 2024Inspection
    Investigated a records-keeping issue and identified that resident records were not kept for at least three years after discharge, violating state rules.
    • Licensing—Failed to assure resident rights
    01 Apr 2024Inspection
    Investigated an allegation of inadequate infection control leadership and found a failure to designate an Infection Control Specialist responsible for implementing infection prevention protocols and serving as the primary contact for outbreaks.
    • Licensing—Failed to assure resident rights
    01 Apr 2024Inspection
    Investigated the allegation of an unsafe medication administration system and found inadequate professional oversight of the medication and treatment administration system.
    • Licensing—Failed to provide a safe medication administration system
    01 Apr 2024Inspection
    Found a deficiency in verifying that direct care staff demonstrated satisfactory performance in any assigned duty.
    • Licensing—Failed to assure resident rights
    01 Apr 2024Inspection
    Found a substantiated violation for failing to provide three daily nutritious meals with snacks seven days a week and not ensuring food was prepared and served according to hygiene rules and USDA guidelines.
    • Licensing—Failed to provide proper food/nutrition
    01 Apr 2024Inspection
    Investigated and found that resident records were not prepared, complete, accurate, or preserved.
    • Licensing—Failed to make facility or resident records accessible
    01 Apr 2024Inspection
    Investigated the allegation of failing to follow the care plan and found a violation related to ensuring the implementation of services.
    • Licensing—Failed to follow care plan
    01 Apr 2024Inspection
    Found that there were not enough qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs.
    • Licensing—Failed to staff as indicated by ABST
    23 Mar 2024Inspection
    Determined a failure to administer medication as ordered occurred.
    • Licensing—Failed to administer medication as ordered
    16 Mar 2024Inspection
    Investigated an allegation that a family member administered an unprescribed medication causing falls, found violations regarding medication management and resident rights, and assessed a fine.
    • Licensing—Failed to provide safe environment
    19 Feb 2024Abuse: Neglect
    Investigated a failure to provide a safe medication administration system; seven of twenty prescribed antibiotic doses were given, delaying wound treatment.
    • Abuse—Failed to provide a safe medication administration system
    18 Jan 2024Inspection
    Investigated a complaint and found a failure to provide a safe medication administration system. The investigation found no abuse by any individual.
    • Licensing—Failed to provide a safe medication administration system
    12 Jan 2024Inspection
    Investigated the allegation of failing to provide service and supervision for a resident with behavioral symptoms and cited a violation of Oregon Administrative Rules.
    • Licensing—Failed to provide service
    09 Jan 2024Abuse: Neglect
    Investigated the complaint and identified deficiencies in monitoring and wound care for pressure injuries, leading to worsening wounds and a hospital visit.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    01 Jan 2024Inspection
    Determined that medication orders were not administered as prescribed.
    • Licensing—Failed to administer medication as ordered
    14 Nov 2023Licensure
    Determined substantial compliance with meal service and food sanitation requirements.
    • Deficiency—Comment
    14 Nov 2023Licensure
    Determined substantial compliance with meals and food sanitation rules following a kitchen inspection.
    • Deficiency—Comment
    15 Oct 2023Inspection
    Investigated a medication safety complaint and found a failure to provide a safe medication administration system, resulting in an incorrect medication being given and increased pain; identified neglect and abuse.
    • Licensing—Failed to provide a safe medication administration system
    14 Oct 2023Inspection
    Investigated a restraint-related case; found neglect and abuse due to administering sedating medications to restrain a resident during nail trimming, and a failure to provide a safe environment.
    • Licensing—Failed to use restraint properly
    02 Jun 2023License Condition
    Found failure to use an ABST as required.
    • Regulatory Action—Failed to use an ABST
    02 Jun 2023License Condition
    Found insufficient direct care staff to meet residents' scheduled and unscheduled needs. Nighttime falls increased due to staffing shortages.
    • Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
    01 Jun 2023Inspection
    Fined $7,500 for failing to report vaccination information for residents, staff, and vaccinated individuals to the proper authority as required by law.
    • Licensing—Failed to submit timely or adequate staffing documentation
    28 May 2023Inspection
    Found a failure to provide a safe medication administration system, resulting in a resident receiving another resident's medication.
    • Licensing—Failed to provide a safe medication administration system
    19 May 2023Inspection
    Investigated and found a violation for failing to submit timely or adequate staffing documentation, and assessed a $7,500 fine.
    • Licensing—Failed to submit timely or adequate staffing documentation
    26 Apr 2023Abuse: Neglect
    Investigated an abuse/neglect allegation and found failures in medication administration and continence care that could harm; a $500 fine was assessed.
    • Abuse—Failed to provide service
    20 Apr 2023Inspection
    Found failure to submit timely or adequate staffing documentation and assessed a $7,500 fine.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 Apr 2023Abuse: Neglect
    Investigated found neglect and abuse due to failure to provide appropriate care, including incontinence care, resulting in discomfort and loss of dignity.
    • Abuse—Failed to provide service
    14 Apr 2023Abuse: Neglect
    Found a failure to provide a safe environment, resulting in neglect and abuse, with a fine assessed.
    • Abuse—Failed to provide safe environment
    04 Apr 2023Abuse: Neglect
    Found the resident did not receive appropriate services, including inadequate skin checks and failure to administer a prescribed PRN antifungal medication. This resulted in discomfort and was considered neglect.
    • Abuse—Failed to provide service
    16 Mar 2023Inspection
    Found that medications were not stored in locked containers in a secured environment, violating the rule.
    • Licensing—Failed to provide a safe medication administration system
    16 Mar 2023Complaint
    Identified multiple deficiencies across governance, resident care, health services, infection control, medication management, staffing, and equipment maintenance.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Facility Administration: Policy & Procedure
    • Deficiency—Resident Services: Adls
    • Deficiency—Service Plan: General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Infection Prevention & Control
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication & Treatment-General
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—General Building: Doors-Walls, Cleanable
    16 Mar 2023Inspection
    Found failure to establish and maintain infection prevention and control protocols, resulting in an unsafe and unsanitary environment.
    • Licensing—Failed to provide infection control
    07 Mar 2023Abuse: Neglect
    Investigated an allegation of unsafe medication administration and found a failure to provide a safe medication administration system, leading to missed eye medication doses and pain for the resident, constituting abuse and neglect.
    • Abuse—Failed to provide a safe medication administration system
    03 Mar 2023Inspection
    Found insufficient qualified awake direct care staff to cover 24-hour needs as required by the rule.
    • Licensing—Failed to provide service
    03 Mar 2023Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in neglect and abuse findings. A $250 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    03 Mar 2023Inspection
    Investigated and found deficiencies in cleanliness of interior and exterior materials and surfaces and in keeping equipment in good repair for health, safety, and comfort.
    • Licensing—Failed to provide service
    03 Mar 2023Inspection
    Found a deficiency in safe medication administration practices. The deficiency was categorized as a minor harm or potential for moderate harm.
    • Licensing—Failed to provide a safe medication administration system
    03 Mar 2023Inspection
    Found failure to provide bathing and hair washing assistance as required.
    • Licensing—Failed to provide service
    03 Mar 2023Inspection
    Investigated an allegation of failing to provide service and found a deficiency due to missing written policies for a 24-hour resident monitoring and reporting system.
    • Licensing—Failed to provide service
    28 Feb 2023Inspection
    Identified a cleanliness deficiency for interior and exterior spaces and surfaces.
    • Licensing—Failed to provide service
    28 Feb 2023Inspection
    Investigated a complaint alleging inadequate awake direct care staffing leading to delayed call-light responses and toileting assistance.
    • Licensing—Failed to provide service
    28 Feb 2023Inspection
    Identified a deficiency in completing quarterly service plans as required by rule.
    • Licensing—Failed to properly plan care
    28 Feb 2023Inspection
    Investigated and found a deficiency in how resident complaints were addressed, with ineffective methods for responding to and resolving complaints in line with state rules.
    • Licensing—Failed to provide service
    28 Feb 2023Inspection
    Investigated an allegation that bathing assistance wasn't provided; found a violation of the bathing assistance requirement.
    • Licensing—Failed to provide service
    24 Feb 2023Inspection
    Found that the staffing plan based on acuity was not updated and the acuity-based staffing tool was not fully implemented.
    • Licensing—Failed to update staffing plan based on ABST
    22 Feb 2023Inspection
    Found a failure to implement a service plan that reflects residents' needs identified in the evaluation.
    • Licensing—Failed to properly plan care
    22 Feb 2023Inspection
    Found insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs of residents.
    • Licensing—Failed to provide service
    18 Jan 2023Inspection
    Found a failure to submit timely weekly reports of vaccinated individuals, residents, and staff for 30 days.
    • Licensing—Failed to submit timely or adequate staffing documentation
    06 Dec 2022Inspection
    Found that the nursing delegation requirement was not met because no Oregon-licensed nurse was regularly scheduled onsite and available for phone consultation.
    • Licensing—Failed to comply with nursing delegation requirement
    24 Nov 2022Inspection
    Found a failure to provide a safe medication administration system and to administer medication as ordered.
    • Licensing—Failed to provide a safe medication administration system
    24 Nov 2022Inspection
    Identified deficiencies in the medication administration system; a medication was not administered as ordered and another was administered late, marking a second such violation within six months.
    • Licensing—Failed to provide a safe medication administration system
    16 Nov 2022Abuse: Neglect
    Investigated a medication safety issue and found a lack of a safe medication administration system that created risk of harm to residents.
    • Abuse—Failed to provide a safe medication administration system
    02 Aug 2022Licensure
    Identified deficiencies in kitchen cleanliness and administration compliance; a follow-up revisit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    02 Aug 2022Licensure
    Identified deficiencies in kitchen cleanliness during the initial visit; subsequent revisit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    01 Apr 2022Inspection
    Found failure to submit timely or adequate weekly vaccination reporting for residents, staff, and vaccinated individuals for 30 days in March 2022.
    • Licensing—Failed to submit timely or adequate staffing documentation
    01 Mar 2022Inspection
    Found that the respondent failed to submit timely or adequate staffing documentation for vaccinated individuals, residents, and staff for 27 days. A $7,500 fine was assessed.
    • Licensing—Failed to submit timely or adequate staffing documentation
    28 Jan 2022Abuse: Neglect
    Found a failure to provide a safe environment for a resident, resulting in neglect and abuse; a fine was assessed.
    • Abuse—Failed to provide safe environment
    24 Jan 2022Abuse: Neglect
    Investigators found that anti-psychotic medications were not provided as prescribed, leading to a resident-to-resident altercation and injuries. A fine of $188 was assessed.
    • Abuse—Failed to provide service
    21 Jan 2022Inspection
    Determined that the allegation about failing to respond to and resolve resident complaints was substantiated. Findings showed that effective methods to address and resolve a long-standing complaint were not developed or implemented.
    • Licensing—Failed to assure resident rights
    13 Jan 2022Inspection
    Investigated the medication administration allegation and verified failure to visually observe a resident take medications as ordered.
    • Licensing—Failed to administer medication as ordered
    02 Jan 2022Abuse: Neglect
    Investigated and found a failure to provide a safe environment resulting in abuse and neglect; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    12 Dec 2021Inspection
    Found deficiencies in safe medication administration practices due to failure to follow doctor orders.
    • Licensing—Failed to provide a safe medication administration system
    12 Dec 2021Inspection
    Investigated a complaint and found insufficient staff to meet residents' scheduled and unscheduled needs, including timely call-light responses.
    • Licensing—Failed to provide service
    31 Oct 2021Inspection
    Investigated the staffing allegation and verified insufficient staff to meet residents' scheduled and unscheduled needs.
    • Licensing—Failed to provide appropriate staffing
    25 Oct 2021Inspection
    Found insufficient staffing to meet scheduled and unscheduled needs of residents, violating Oregon Administrative Rules.
    • Licensing—Failed to provide service
    14 Oct 2021Inspection
    Found insufficient staff to meet residents' scheduled and unscheduled needs, delaying responses to call lights and timely medication administration.
    • Licensing—Failed to answer call light in a timely manner
    17 Sept 2021Inspection
    Investigated the complaint and found insufficient staff to meet residents' scheduled and unscheduled needs and to provide housekeeping.
    • Licensing—Failed to provide appropriate housekeeping services
    17 Sept 2021Inspection
    Investigated the allegation and found a staff training deficiency.
    • Licensing—Failed to provide appropriate staffing
    17 Sept 2021Inspection
    Determined that housekeeping services were not provided as required.
    • Licensing—Failed to provide appropriate housekeeping services
    09 May 2021Abuse: Neglect
    Investigated and found that staff failed to follow a resident's care plan to empty a catheter bag, resulting in neglect and abuse; a $1,000 fine was assessed.
    • Abuse—Failed to follow care plan
    06 May 2021Abuse: Neglect
    Investigated an allegation and found that the care plan was not followed, resulting in abuse/neglect. A $1000 fine was assessed.
    • Abuse—Failed to follow care plan
    16 Apr 2021License Condition
    Investigated the allegation of inadequate administrative oversight and found violations for failing to provide needed/necessary services.
    • Regulatory Action—Failed to provide service
    10 Mar 2021Abuse: Neglect
    Investigated and found that a resident’s changing condition was not addressed, contributing to weight loss and dehydration. A $250 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    21 Feb 2021Inspection
    Determined that the allegation of failing to assist with dressing or grooming was verified.
    • Licensing—Failed to assist with dressing or grooming
    21 Feb 2021Inspection
    Investigated the hygiene-related allegation and found residents were not assisted with bathing and toileting.
    • Licensing—Failed to provide or assist with hygiene
    21 Feb 2021Inspection
    Investigated and found service plans for residents were not updated quarterly, violating the applicable rule.
    • Licensing—Failed to care plan in accordance with assessment
    30 Jan 2021Inspection
    Found insufficient staffing to meet residents' scheduled and unscheduled needs.
    • Licensing—Failed to provide appropriate staffing
    30 Jan 2021Inspection
    Investigated and verified that twice-daily oral care was not provided as outlined in the resident's service plan.
    • Licensing—Failed to follow care plan
    30 Jan 2021Abuse: Neglect
    Found neglect and abuse due to failure to ensure dental treatment for a resident, and a $500 fine was assessed.
    • Abuse—Failed to assure dental treatment
    04 Dec 2020Inspection
    Investigated the allegation that a call system connecting resident units to staff pagers was not maintained and verified the deficiency.
    • Licensing—Failed to maintain functional door alarm or call system
    04 Dec 2020Inspection
    Concluded that resident service plans were not updated.
    • Licensing—Failed to follow care plan
    04 Dec 2020Inspection
    Investigated the allegation and found that information about the method for evaluating service needs and assessing costs was not provided.
    • Licensing—Failed to communicate necessary information
    04 Dec 2020Inspection
    Identified an ineffective method for responding to and resolving resident complaints.
    • Licensing—Failed to communicate necessary information
    04 Dec 2020Inspection
    Investigated a staffing allegation and found direct care staffing levels insufficient to meet residents' scheduled and unscheduled needs.
    • Licensing—Failed to provide appropriate staffing
    04 Dec 2020Inspection
    Found that physician orders were not carried out as prescribed.
    • Licensing—Failed to follow care plan
    04 Dec 2020Inspection
    Investigated the allegation that the administrator failed to implement services per resident service plans; findings verified the failure to implement as required.
    • Licensing—Failed to follow care plan
    03 Dec 2020Inspection
    Found that information about evaluating service needs and costs for provided services was not communicated.
    • Licensing—Failed to communicate necessary information
    03 Dec 2020Inspection
    Determined that the allegation of failing to communicate necessary information and to coordinate off-site health services for residents who cannot or choose not to self-manage their health services was verified.
    • Licensing—Failed to communicate necessary information
    03 Dec 2020Inspection
    Found that care planning failed to update resident service plans.
    • Licensing—Failed to properly plan care
    01 Dec 2020Inspection
    Investigated the allegation and verified that services based on resident service plans were not implemented.
    • Licensing—Failed to follow care plan
    01 Dec 2020Inspection
    Investigated the allegation that medical treatment was not provided as ordered and confirmed non-compliance with physician orders.
    • Licensing—Failed to provide medical treatment as ordered
    01 Dec 2020Inspection
    Investigated and verified that resident service plans were not updated.
    • Licensing—Failed to follow care plan
    20 Nov 2020Inspection
    Found a deficiency in infection control and substantiated a Level 2 licensing violation.
    • Licensing—Failed to provide infection control
    15 Oct 2020Inspection
    Found insufficient awake qualified direct care staff to meet scheduled and unscheduled resident needs.
    • Licensing—Failed to provide appropriate staffing
    15 Oct 2020Inspection
    Investigated an allegation about resident records and found that service plans did not reflect residents' needs or were not readily accessible to staff.
    • Licensing—Failed to keep resident record current or accurate
    14 Oct 2020Abuse: Neglect
    Found that staff failed to follow the resident’s care plan, resulting in an unwitnessed fall with head injury and inadequate two-hour checks.
    • Abuse—Failed to follow care plan
    14 Oct 2020Inspection
    Investigated and found a deficiency related to failing to promptly investigate all reports of abuse and suspected abuse and to take measures necessary to protect residents.
    • Licensing—Failed to report potential or suspected abuse
    14 Oct 2020Inspection
    Identified a deficiency in training to determine direct care staff competency. The finding showed no program to assess competency through evaluation, observation, or written testing.
    • Licensing—Failed to assure a qualified caregiver was present
    14 Oct 2020Inspection
    Found insufficient qualified awake direct care staffing to meet residents' 24-hour needs.
    • Licensing—Failed to provide appropriate staffing
    06 Oct 2020Inspection
    Investigated the allegation and found a deficiency in maintaining a safe environment, including PPE noncompliance and coded alerts for PPE when state workers were on site.
    • Licensing—Failed to maintain a safe physical environment
    06 Oct 2020Inspection
    Verified that a daily program of social and recreational activities based on residents' interests and needs was not provided.
    • Licensing—Failed to provide appropriate activities
    06 Oct 2020Inspection
    Determined that there were not enough qualified awake direct care staff to meet residents' 24-hour needs.
    • Licensing—Failed to assure a qualified caregiver was present
    06 Oct 2020Inspection
    Investigated and found deficiencies in care and cleanliness, including lack of bathing, toileting, and bladder/bowel management, and housekeeping.
    • Licensing—Failed to provide or assist with hygiene
    11 Sept 2020Abuse: Neglect
    Identified abuse and neglect violations; failed to provide prescribed care, including oxygen and pain management orders, risking the resident's care, and a fine was assessed.
    • Abuse—Failed to provide service
    15 Jul 2020Abuse: Neglect
    Investigated a complaint and found the facility failed to provide adequate health assessment and monitoring during a change in condition, leading to harm; a $500 fine was assessed.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    10 Jun 2020Abuse: Neglect
    Investigated allegations of abuse and neglect found failure to assess and intervene with a resident's changing condition, resulting in the resident becoming lost and at risk of serious harm.
    • Abuse—Failed to provide safe environment
    22 May 2020Abuse: Neglect
    Investigated an allegation of neglect and abuse due to failure to plan care for a resident with challenging behaviors; determined improper care planning and a sanction was imposed.
    • Abuse—Failed to properly plan care
    10 Feb 2020Inspection
    Investigated an allegation of failing to properly plan care and found service plans were not updated to reflect residents' needs at move-in, within 30 days, and quarterly per the rule.
    • Licensing—Failed to properly plan care
    10 Feb 2020Inspection
    Investigated the allegation of an unsafe environment and found interior materials and surfaces were not kept clean or in good repair.
    • Licensing—Failed to maintain a safe physical environment
    23 Jan 2020Abuse: Neglect
    Found neglect and abuse due to failure to provide basic care and services; a $250 fine assessed.
    • Abuse—Failed to provide service
    22 Oct 2019Abuse: Neglect
    Found a failure to provide a safe medication administration system, which led to ongoing inflammation after surgery and the need for additional medication.
    • Abuse—Failed to provide a safe medication administration system
    22 Sept 2019Abuse: Financial abuse
    Determined that a resident was financially exploited and a care deficiency led to financial loss.
    • Abuse—Failed to protect resident from financial exploitation
    27 Aug 2019Abuse: Financial abuse
    Investigated the financial exploitation allegation and determined there was a failure to protect a resident from financial exploitation, resulting in financial loss.
    • Abuse—Failed to protect resident from financial exploitation
    26 Jun 2019Abuse: Neglect
    Found neglect causing physical harm to a resident; a fine was assessed.
    • Abuse—Failed to assure resident was safe
    10 Sept 2018Abuse: Neglect
    Investigated the allegation of neglect; found that basic care was not provided, resulting in physical harm to a resident.
    • Abuse—Failed to assure resident was safe
    13 Jul 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and found failure to follow the care plan, resulting in harm; a fine was assessed.
    • Abuse—Failed to follow care plan
    17 Jun 2018Inspection
    Investigated and found that care planning failed to ensure a safe environment, creating a risk of serious harm.
    • Licensing—Failed to properly plan care
    02 May 2018Inspection
    Determined that a failure to prepare and serve food in compliance with food sanitation rules occurred, including unlabeled foods.
    • Licensing—Failed to assure food safety
    09 Apr 2018Abuse: Neglect
    Investigated and found a failure to provide a safe environment for two residents, resulting in a $338 fine.
    • Abuse—Failed to provide safe environment
    10 Mar 2018Abuse: Neglect
    Investigated the allegation and found failure to follow the care plan.
    • Abuse—Failed to follow care plan
    18 Jan 2018Abuse: Neglect
    Determined that two residents did not receive medications as ordered. The neglect allegation was substantiated.
    • Abuse—Failed to assure timely medical treatment
    15 Sept 2017Abuse: Neglect
    Investigated the complaint and found a failure to provide a safe environment for the reported victim.
    • Abuse—Failed to provide safe environment
    03 Aug 2017Abuse: Neglect
    Investigated an allegation of neglect and found that staff failed to assess and intervene when a resident's condition changed.
    • Abuse—Failed to intervene when resident's condition changed
    20 Jul 2017Abuse: Financial abuse
    Investigated a financial exploitation allegation and found a failure to protect a resident from loss of property.
    • Abuse—Failed to protect resident from financial exploitation
    21 Jun 2017Inspection
    Found a deficiency in the medication administration system that could lead to a medication error.
    • Licensing—Failed to provide a safe medication administration system
    05 Apr 2017Abuse: Verbal/Mental abuse
    Investigated a verbal/mental abuse allegation and found a violation for failing to protect a resident from inappropriate comments and actions.
    • Abuse—Failed to protect resident from verbal abuse
    07 Mar 2015Inspection
    Found a deficiency for failing to provide a safe environment.
    • Licensing—Failed to provide safe environment
    16 Feb 2011Inspection
    Found failure to follow the care plan.
    • Licensing—Failed to follow care plan
    08 Jun 2010Inspection
    Investigated allegation of unsafe medication practices and found an inadequate medication system.
    • Licensing—Failed to provide a safe medication administration system
    07 Apr 2010Abuse: Neglect
    Investigated a medication-safety concern and found an inadequate medication system.
    • Abuse—Failed to provide a safe medication administration system
    07 Jan 2010Abuse: Neglect
    Investigated an allegation of neglect and identified an inadequate screening or assessment.
    • Abuse—Failed to perform adequate screening or assessment

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