Cedarbrook Lodge Senior Living

Last inspection

July 14, 2026

Inspections

3, 6 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

1

Regulatory actions

0

Fines assessed

$4,250.00 (5 violations)

Current owner since

October 1, 2025

Inspections

• July 14, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 2, 2024: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected June 16, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected June 16, 2024
• January 9, 2023: Validation, 4 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected April 24, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected April 24, 2023
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected April 24, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected April 24, 2023

Substantiated abuse or neglect

• May 5, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. From approximately May 02, 2024, through May 05, 2024, the AV suffered approximately four falls at their bedside without appropriate progressive interventions put into place after each fall. After the final fall on or about May 05, 2024, the AV complained about back pain. On or about May 13, 2024, the AV was sent to the ER and was diagnosed with a compression fracture, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 9, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s repeated falls. From approximately January 14, 2023, through August 29, 2023, the AV suffered approximately 5 falls, some resulting in injury. On or about August 29, 2023, the AV fell for approximately the 5th time while self-transferring resulting in a lump on their head and pain on their face. There was no documented evidence the facility implemented interventions to assist the AV with ambulation or transferring. The lack of appropriate interventions to help mitigate falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 6, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall risk. Between approximately November 03, 2023, through November 08, 2023, the AV suffered approximately three falls. On or about November 06, 2023, the AV suffered a fall resulting in a fracture to their ankle, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 8, 2023: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  According to the documentation, the facility failed to ensure the care plan was being followed by escorting the Alleged Victim (AV) on or about August 08, 2023, AV was walking unescorted to the dining room leaning heavily to one side. AV fell and hit their head on the floor sustaining a fracture to their T1 vertebrae. The AV was care planned to be escorted to and from their room as part of fall interventions. The failure resulted in the AV sustaining a fall and fracturing a vertebrae in their back, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 21, 2022: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. Between January 2022 through October 2022, the AV suffered numerous non-injury falls and the facility failed to implement appropriate fall interventions to mitigate their frequent fall risk. On or about November 21, 2022, the AV suffered an unwitnessed fall resulting in a skin tear and multiple fractured ribs requiring a hospital stay. Which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 9, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) receives his/her medication from facility staff. On or about April 9, 2024, AV received a double dose of his/her medication. Alleged Perpetrator #2 (AP2) gave AV his/her medication but forgot to sign off his/her medication as being given and another staff gave AV the same medication again. AV did not have any adverse effects from the double medication, however, AV was placed at risk for harm by being given the medication twice. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure 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.