Hawthorne Gardens Memory Care Community

Last inspection

December 18, 2025

Inspections

6, 40 deficiencies cited

Substantiated abuse

15

Substantiated licensing violations

24

Regulatory actions

3

Fines assessed

$6,253.00 (16 violations)

Current owner since

October 1, 2023

License conditions and other regulatory actions

• July 11, 2025 to October 6, 2025: License Condition, Failed to provide safe environment RCFCD25-00707; incident: CALMS - 00082626
  ODHS completed a Change of Ownership Survey 50R350-CHOW004869 on or about June 11, 2025, at Hawthorne Gardens Memory Care Community and determined the facility was not in substantial compliance with Oregon Administrative Rules and that the facilitys non-compliance constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)
• October 3, 2024 to January 9, 2025: License Condition, Failed to provide safe environment RCFCD24-01022; incident: CALMS - 00063090
  On or about September 23, 2024, the Department opened an APS investigation, and based on preliminary information ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0110 (Definitions)
• April 16, 2021 to November 29, 2021: License Condition, Failed to provide service RCFCD21-02111; incident: CALMS - 00012887
  Per re-licensure survey (JW5E11) the facility failed to provide effective administrative oversight to ensure quality care and services were rendered in the facility.
  Rules: 411-054-0002; 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0140 (Responsibilities of Administration); 411-057-0155 (Staff Training Requirements); 411-057-0160 (Resident Services in a Memory Care Community); 411-057-0410

Inspections

• December 18, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• June 11, 2025: Change of Owner, 25 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 2, scope L2 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  Show all 26

  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0282: RN Delegation and Teaching severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0435: Emergency and Disaster Planning severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated
  • C0510: General Building Exterior severity level 2, scope L2 Pattern
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern
  • L0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Isolated
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated
  • Z0168: Outside Area severity level 2, scope L2 Widespread
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread
• November 12, 2024: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• April 1, 2024: Complaint Investig., 9 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Widespread
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Widespread
  Show all 9

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Widespread
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Pattern
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Widespread
• November 14, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 2, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 1, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 1, 2022

Substantiated abuse or neglect

• July 4, 2025: Failed to address resident's behavior Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. The AV is care planned to require frequent supervision and oversight to protect the AV. Witness 7 (W7) has a history of sexually inappropriate behaviors towards the AV and other residents. According to an investigation, on or about, June, 4 2025, the AV and W7 were observed exiting W7's room. The AV was reported to appear highly agitated and angry when questioned about the incident. The facility failed to implement adequate safety interventions to prevent W7 from engaging in sexually inappropriate behaviors. The facility failed to appropriately care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

• March 31, 2025: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) relies on the facility for their care. The AV requires the assistance of two staff and the use of a sit to stand device for all transfers. According to an investigation, the AV incurred multiple injuries during transfers utilizing the sit to stand device, including skin tears and bruising, between approximately May 4, 2025, and May 26, 2025. The facility failed to evaluate and monitor the injuries and failed to develop interventions to minimize future incidents, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

• February 18, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care. Witness 5 (W5) has a history of resident-to-resident altercations and is care planned to be redirected by staff when agitated and acting aggressively. According to an investigation, on or about February 18, 2025, W5 was showing signs of agitation all day and pushed AV against a wall and AV then fell to the ground, resulting in AV having a bump to the back of the head. The facility failed to monitor W5's behaviors and provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• September 21, 2024: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-057-0170 (Physical Design, Environment, and Safety)
  State’s 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.

• July 5, 2024: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about July 5, 2024, AV did not receive cough medication timely, as ordered. AV had an order for cough medication to be administered as needed. Witness 1 (W1) notified the facility of AV's need for the medication, but the medication was not administered timely, resulting in unreasonable discomfort to AV. The facility failed to administer medication timely, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 25, 2026: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about April 24, 2026, Alleged Perpetrator 2 (AP2) took two bottles of the AV's liquid narcotic pain medication. AP2's actions are a violation of resident rights, considered financial exploitation, and constitute abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

• December 22, 2025: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Based on interview and record review, the facility failed to comply with Change of Conditions and Monitoring requirements. The facility’s failure is a violation of Oregon Administrative Rules.

• December 13, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about December 13, 2025, Alleged Perpetrator 2 (AP2) did not follow proper procedure for medication storage and management. Bottles of medications were left unattended in the AV's room, and the AV took two pills placing the AV at risk of harm. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

• October 15, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• August 15, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 35 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.