Middlefield Oaks Assisted Living Community

Last inspection

July 7, 2026

Inspections

8, 28 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

10

Regulatory actions

3

Fines assessed

$2,500.00 (4 violations)

Current owner since

November 17, 2006

License conditions and other regulatory actions

• August 7, 2025 to March 24, 2026: License Condition, Failed to use an ABST ALFCD25-00327; incident: OR0004985600
  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• June 16, 2023 to September 29, 2023: License Condition, Failed to use an ABST ALFCD23-00416; incident: CALMS - 00043638
  The facility failed to ensure an Acuity Based Staffing Tool (ABST) assessment was completed for each resident before move in, and was reviewed and amended for each resident whenever there was a significant change of condition or at least quarterly.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• November 2, 2022 to December 20, 2022: License Condition, Failed to care plan in accordance with assessment ALFCD22-01148; 2 incidents: OR0003777101, OR0003777100
  The facility failed to fully implement and update an acuity-based staffing tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• July 7, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• August 13, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• May 9, 2025: Complaint Investig., 1 deficiency cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
• August 14, 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 October 13, 2024
• November 27, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• May 12, 2023: 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

  According to documentation, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about May 12, 2023, AV suffered an unwitnessed fall resulting in a bruise on h/h right arm. 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.

• November 30, 2022: Failed to provide medical treatment 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

  Alleged Victim (AV) relies on the facility for his/her care. On or about November 16, 2022, AV had a hip surgery. AV was returned to the facility on or about November 18, 2022, after the surgery with orders for his/her dressing to remain on at all times and to call AV’s surgeon if the bandages was saturated. Between November 18th, through 24th, AV’s bandages were documented to be soaked and saturated at least twice. No call to AV’s surgeon was made. As a result, on or about November 30, 2022, AV was diagnosed with an infection at the surgical site and had to be placed on antibiotics. The facility failed to follow AV’s discharged instructions regarding wound care and dressing maintenance, which is a violation of resident rights, is neglect of care and constitutes abuse.

• May 10, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. AV moved into the facility on mid-October 2021 and as of May 11, 2022, AV did not have a care plan in place. AV stated he/she was not on a shower schedule and had not been getting regular showers. AV was seen by his/her PCP on May 5, 2022, and a Foley catheter placement was suggested. AV is unable to get to the toilet in time without assistance. AV has experienced wit times to be toileted. AV has not been cleaned properly after toileting and feces has been smeared on his/her sheets. AV states staff would respond to the call light but come in and turn it off without attending to his/her needs and leave. Witness 1 (W1) confirmed AV is rights about toileting, showers and care plan, AV has overheard staff telling AV to wait to use the bathroom. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

• October 20, 2021: Failed to protect resident from rape Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 411-054-0030 (Resident Services); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Witness #1 (W1) has a history of alcohol abuse and is known to have aggressive behaviors when he/she has been drinking. On or about October 20, 2021, W1 had been drinking and was observed to be antagonistic and agitated. On this date, W1 entered the Alleged Victim's (AV) room and forced AV to have sexual relations against AV's will. AV was sent to the hospital for an examination and was determined to have bruising in multiple areas, consistent with AV's story of being raped. The facility failed to protect AV from rape, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• August 4, 2025: Failed to perform adequate screening or assessment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0045 (Resident Health Services)
  State’s findings

  Based on interview and record review, conducted during a site visit on 08/04/25, the facility’s failure to ensure RN notification of nursing services as identified in service plan was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Compliance Specialist (CS) reviewed Resident’s 1’s (R1) service plan dated 05/11/25, TSP dated 07/26/25, policy and procedure for monitoring and reporting dated 12/01/23, progress notes/observation notes dated 06/01/25 through 07/27/25, and alert charting dated 06/01/25 through 07/27/25, which indicated the following: Policy and Procedure for monitoring and reporting; stated staff are to report changes in resident status to RN (Director of Health Services). Staff were to document all communication in the resident’s record with all providers. Staff were documenting alert charting on Resident 1, but failed to notify the RN, LPN, or follow the chain of reporting in the Policy and procedure. TSP in place for monitoring resident, but did not specify who/what/when to report to while monitoring. The following indicated: Progress notes placed R1 on alert charting twice for an open rash on the buttocks and for an open area on the coccyx area. No documentation identified that RN, LPN, or Policy and procedure was followed for notifying a change in residents’ status. No TSP or service plan changes were provided by the facility for 07/26/25; or alert charting specifying who/what/when to report while monitoring resident. Resident Monitoring dated 07/21/25 through 07/28/25, skin wound monitor for increased pain, redness, and bleeding. The resident has an open bleeding/raw/red/rashy area on the buttocks and coccyx. Note placed by RCC, RN on leave. The facility failed to ensure RN notification of nursing services for residents' change in status as identified in the service plan. In an interview, Staff 1 stated the following: The RCC did not notify RN, LPN, or Corporate RN for consultation. In an interview with Staff 2 and Staff 4, they both stated that the RN was on vacation at the time of the incident, and the LPN was not notified by staff of R1's condition. The facility’s failure to ensure RN notification of nursing services as identified in the service plan was substantiated.

• July 27, 2025: Failed to adequately plan discharge Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Based on interview and record review, conducted during a site visit on 08/04/25, the facility’s failure to comply with the Monitoring requirements was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Compliance Specialist (CS) reviewed Resident’s 1’s (R1) service plan dated 05/11/25, progress notes/observation notes dated 06/01/25 through 07/27/25, physician orders 06/01/25 through 07/27/25, after-visit summaries dated 06/01/25 through 07/27/25, discharge summaries 06/01/25 through 07/27/25 , communications with PCPs and outside providers 06/01/25 through 07/27/25, and incident reports dated 06/01/25 through 07/27/25, which indicated the following: 07/12/25-07/13/25 – R1 admitted to hospital for surgical procedure 07/12/25 Esophogastroduodenoscopy w/biopsy. Released back to the facility on 07/13/25 with aftercare instructions. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to. R1 was placed on alert charting after return from the hospital, diagnosed GI Bleed. Discharge summary lists a history of chronic illnesses as reasons for hospital stay, none of which include wounds or wound care. 07/21/25-07/23/25- CG reported rash on R1 buttocks and scrotum area. R1 requested RN from an outside provider to assess rash. Witness 1 (W1) sent in orders for ointment on 07/22/25 to be self-administered by R1. During a phone call on 08/04/25 with Witness 1 s/he assessed the resident on 07/15/25 and 07/23/25, s/he also stated that R1 refused to let him/her look at his/her buttocks area. Facility faxed PCP that R1 had some red-rashy areas that were open and bleeding on the buttocks and coccyx area. R1 was placed on alert charting. No RN notes documented in progress notes regarding R1's rash on scrotal or buttocks area. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to. 07/25/25-07/26/25 – Resident was seen at a medical center for scrotal ulcer and buttocks, prescribed cream and donut for healing of the area. 07/26/25 resident tested positive for COVID. The resident was placed on alert charting. No RN notes documented in progress notes regarding R1's rash in scrotal or buttocks area. TSPs were not available to all staff on every shift and didn’t include who/what/when to report to. 07/27/25- Resident sent out to hospital. The above indicated the facility failed to comply with monitoring requirements for R1 on the above dates by not providing a monitoring plan to staff on every shift. In an interview, Staff 1 stated the following: The facility had a COVID outbreak during this time, and the facility was moving over to a new system; this could have been why a monitoring plan or TSPs were not done. R1 was on alert charting, and staff were following the physician's orders and charting any change of condition for R1. In an interview with Staff 2 and Staff 4, they both stated that due to the RN being on vacation and COVID outbreak, staff called an outside provider for an assessment on R1 instead of the LPN at the time. R1 was unable to be interviewed or observed due to being out of the facility. The facility’s failure to comply with the monitoring requirements was substantiated.

• November 8, 2023: Failed to provide safe environment Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; 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

  According to documentation, the AP2 failed to follow the Alleged Victim’s care plan and facility protocol to not deliver medication directly to AV. The failure resulted AV experiencing an overdose in medication and was sent the hospital and later passed away. AP2’s actions are considered neglect of care and constitutes abuse. The facility failed to protect AV from neglect, which is a violation of Oregon Administrative Rules.

• August 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about August 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from July 1, 2022 to July 31, 2022, for a total of 30 days.

• May 23, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0050 (Infection Prevention and Control)
  State’s findings

  The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment to include protocols to prevent the development and transmission of communicable diseases, 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 85 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.