Cedarbrook Place Memory Care

Last inspection

March 10, 2026

Inspections

6, 20 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

3

Regulatory actions

0

Fines assessed

$1,502.00 (7 violations)

Current owner since

October 1, 2025

Inspections

• March 10, 2026: Change of Owner, 6 deficiencies cited report
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Widespread
• March 9, 2026: 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
• August 19, 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
• July 25, 2024: 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 September 23, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 23, 2024
• June 21, 2023: 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 August 20, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 20, 2023
• September 19, 2022: Validation, 6 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected February 25, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected November 19, 2022
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern, corrected November 19, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated, corrected February 25, 2023
  Show all 8

  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected February 25, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected November 19, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected November 19, 2022

Substantiated abuse or neglect

• July 30, 2025: Failed to provide safe environment 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

  According to the documentation, the facility failed to properly care plan appropriate interventions to prevent the Alleged Victim (AV) from going into Witness 1’s (W1) room which causes agitation and aggression from W1. W1 has a known history of agitation when residents enter their room without permission. On or about July 14, 2025, AV wandered into W1’s room causing W1 to become agitated. There were no documented interventions placed to ensure other residents did not enter W1’s room. On or about July 30, 2025, AV wandered into W1’s room again. This time, W1 pinned the AV against the wall and hit and shook them. Staff intervened and separated them. The failure to properly care plan interventions for residents wandering into W1’s room led to a physical interaction between the two residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 3, 2025: Failed to properly plan care 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1’s (W1) pattern of physical altercations with other residents. On or about May 03, 2025, W1 saw the Alleged Victim (AV) holding hands with another resident. W1 became upset and hit AV’s right shoulder. Witness statements concluded W1’s service plan was not updated with interventions for their known aggressive behavior. The AV showed signs of emotional distress and anxiety after the altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 19, 2025: Failed to properly plan care 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1’s (W1) aggressive behavior towards the Alleged Victim (AV). On or about April 18, 2025, the AV wandered into W1’s room. The AV exited and W1 followed them out and started slapping the AV. On or about April 19, 2025, W1 came out of their room, saw the AV in the dining room and started yelling and hitting the AV. After the incident on or about April 18, 2025, there were no documented interventions to prevent further resident to resident altercations between the AV and W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 28, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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) fall history. Between Approximately April 25, 2024, through May 15, 2024, the AV suffered approximately six falls. There is no documented evidence the facility implemented appropriate interventions to prevent future falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 7, 2022: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 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 facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV is to be given pain medication every hour as needed for pain. According to documentation H/S went without the medication from on or about June 30, 2022 – July 4, 2022, the failed resulted in AV experiencing pain and unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 22, 2022: Failed to follow care plan 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

  According to the documentation, the facility failed to follow the service plan for the Alleged Victim (AV) for routine checks and nighttime care. AV was service planned to have two hour checks and a midnight check for routine bedtime care. On or about May 21, 2022, Staff did not check on the AV after 8:00 pm check. The AV was service planned to have a midnight bedtime care for catheter care. at around 4:00 am, the AV was found in their bathroom with urine and feces on the AV’s shower seat. The failure to follow safety checks every two hours as outlined on the AV’s service plan caused the AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 7, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about January 7, 2022, AV suffered an unwitnessed fall, resulting in an injury to H/H head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 6, 2026: Failed to provide inservice Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The facility allegedly failed to provide in-service training to AP2. An investigation determined no abuse occurred. The facility failed to assure the Alleged Victim's rights. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) sexually abused AV was investigated and determined to be not substantiated.

• June 4, 2026: Failed to provide inservice 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility allegedly failed to provide in-service training for staff, resulting in risk of harm for the Alleged Victim (AV). According to an investigation, the facility failed to ensure the service plan was followed. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be substantiated. AP2 failed to follow the care plan for AV, resulting in unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse.

• February 16, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 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

  On or about February 16, 2024, Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system. AP2 administered another resident’s medication to The Alleged Victim (AV), resulted in AV experienced unreasonable discomfort. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse, 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 15 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.