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Assisted Living and Memory Care

Middlefield Oaks Memory Care Community

1500 Village Drive, Cottage Grove, OR 97424 · Map
Licensed for 36 residents

State license active
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Middlefield Oaks Memory Care Community is a state-licensed assisted living, memory care community in Cottage Grove, Oregon. It is licensed for 36 residents. Lilisity publishes no score or ranking for this community; the details below come from the state licensing record.

Assisted LivingAlso memory care
36 residentsLicensed capacity
State licensedResidential care facility (memory care endorsement)
$4,600 to $5,800/moTypical assisted living start in Oregon, from 108 communities that publish prices

Prices

This community does not publish its prices.

Area costs

Assisted Living in Oregon typically starts at $4,600 to $5,800 a month. Based on 108 communities that publish prices. These are area figures, not this community's price.
Memory Care in Oregon typically starts at $6,000 to $8,200 a month. Based on 78 communities that publish prices. These are area figures, not this community's price.

Lilisity’s independent report

What the public record shows

Gathered by Lilisity from state and federal sources. Communities can’t edit this part of the page.

State inspections

40Deficiencies cited
43Substantiated violations

Last inspection: Jul 7, 2026. See the record

License

Active, 36 residents

Residential Care Facility (Memory Care endorsement) 50R345.

State inspection record40 deficiencies, 43 violations
Last inspection
July 7, 2026
Inspections
9, 40 deficiencies cited
Substantiated abuse
36
Substantiated licensing violations
7
Regulatory actions
2
Fines assessed
$17,626.00 (35 violations)
Current owner since
November 17, 2006

License conditions and other regulatory actions

  • August 12, 2025 to April 21, 2026: License Condition, Failed to staff as indicated by ABST RCFCD25-00770; incident: CALMS - 00078972
    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)
  • June 16, 2023 to September 26, 2023: License Condition, Failed to use an ABST RCFCD23-00751; incident: CALMS - 00043618
    The facility failed to implement an acuity based staffing tool (ABST) that met the regulation.
    Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

  • July 7, 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 13, 2025: Kitchen, 2 deficiencies cited report
    • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
    • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
    • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • August 14, 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 October 13, 2024
    • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 13, 2024
  • November 27, 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 January 26, 2024
    • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected January 26, 2024
  • April 17, 2023: Validation, 26 deficiencies cited report
    • C0000: Comment severity level 0
    • C0156: Facility Administration: Quality Improvement severity level 3, scope L3 Pattern, corrected July 14, 2023
    • C0231: Reporting & Investigating Abuse-Other Action severity level 3, scope L3 Pattern, corrected October 23, 2023
    • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected July 14, 2023
    • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected October 23, 2023
    • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 23, 2023
    • C0270: Change of Condition and Monitoring severity level 3, scope L3 Pattern, corrected October 23, 2023
    • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected July 14, 2023
    • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected July 14, 2023
    • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected July 14, 2023
    • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected July 14, 2023
    • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected July 14, 2023
    • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected October 23, 2023
    • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected July 14, 2023
    • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected July 14, 2023
    • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected July 14, 2023
    • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected October 23, 2023
    • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected October 23, 2023
    • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected October 23, 2023
    • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected July 14, 2023
    • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected July 14, 2023
    • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 23, 2023
    • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected October 23, 2023
    • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Pattern, corrected October 23, 2023
    • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected July 14, 2023
    • Z0164: Activities severity level 2, scope L2 Pattern, corrected October 23, 2023
    • Z0168: Outside Area severity level 2, scope L2 Pattern, corrected July 14, 2023
    • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected October 23, 2023
    • Z0176: Resident Rooms severity level 2, scope L2 Pattern, corrected July 14, 2023
Show all 9
  • April 14, 2023: Complaint Investig., 1 deficiency cited report
    • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • January 17, 2023: Complaint Investig., 1 deficiency cited report
    • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
    • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • December 5, 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 April 1, 2023
    • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated, corrected April 1, 2023
    • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 1, 2023
  • September 30, 2022: Complaint Investig., 2 deficiencies cited report
    • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
    • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
    • C0260: Service Plan: General severity level 2, scope L2 Pattern

Substantiated abuse or neglect

  • February 16, 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); 411-054-0036 (Service Plan – General); 411-054-0070 (Staffing Requirements and Training)
    State’s findings

    The Alleged Victim (AV) and Witness 1 (W1), both have impaired memory, reside at AP1, which is responsible for ensuring their safety and providing appropriate care planning. W1 and AV were roommates upon W1’s move into AP1. According to AP1 staff, W1 began exhibiting inappropriate sexual behaviors shortly after moving in. W1 behaviors were directed toward both staff and residents of the opposite gender and included attempts to engage others in sexual activity, inappropriate touching, and inviting residents to W1’s room. W1 was also found in bed with another resident. On or about February 16, 2025, W1 was observed with pants down and genital area exposed, touching AV’s genital area. AV lacks the capacity to consent to sexual contact. Following the incident, staff noted changes in AV’s behavior, including becoming quiet, aggravated, and more upset. Although some staff attempted to supervise and redirect W1, AP1 failed to implement interventions or increase staffing to adequately address W1’s behavior until after multiple incidents had occurred. The facility failed to provide a safe environment, failed to appropriately care plan, and did not implement reasonable measures to protect AV and other residents from W1 increasing sexual behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • February 2, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0070 (Staffing Requirements and Training)
    State’s findings

    The Alleged Victim (AV) is a resident of AP1 and depends on AP1 staff for assistance with activities of daily living and overall safety. According to AV’s care plan, dated on or about January 27, 2025, AV requires a two-person assist for all transfers using a mechanical Hoyer lift. AP1 staff have not received training on the proper use of the Hoyer lift. As a result of an improper transfer, AV has bruising to the right inner thigh. The facility’s failure to ensure a safe environment and to adequately train staff in the use of required equipment constitutes a violation of the resident’s rights. This failure is considered neglect of care and constitutes abuse.

  • August 31, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
    State’s findings

    Alleged Victim (AV) is known to walk around the facility and to try to get other residents to walk with AV when AV is feeling anxious. AV has scheduled and PRN Lorazepam available to AV. AV utilizes this medication frequently for extreme anxiety. There is nothing in AV’s care plan that states what staff are to do regarding AV’s anxiety. There is nothing in writing for staff to refer to regarding AV’s anxiety and any interventions that can be done to mitigate the risk of an altercation with another resident. W1 is known to not like being touched by residents or staff. W1 has severe hallucinations. AV and W1 have history of one negative interaction that occurred in July 2024,AV was trying to get W1 to walk with AV and W1 said no. On or about August 31, 2024, AV wandered into W1's room and attempted to get W1 to walk with AV. W1 pushed AV to the ground and yelled that W1 was done being touched by AV. Staff separated AV and W1 and helped AV off the ground. AV sustained an injury, and redness was noted to AV's back between the shoulder blades. AV was noticeably anxious throughout the day leading up to this event with W1. Staff had successfully kept AV occupied throughout the day by walking with AV to keep AV from engaging in any negative interactions with other residents. The event with W1 occurred when staff left AV alone while AV was feeling extreme anxiety. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing behaviors/anxiety, and failed to provide clear direction to staff on providing services to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • January 8, 2024: Failed to provide safe environment 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)
    State’s findings

    The facility failed to provide a safe environment. On or about January 8, 2024, according to documentation the Alleged Victim (AV) sustained fractured ribs from an unknown origin and was sent to the Emergency Department for treatment. The failure resulted in AV experiencing pain and unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • November 2, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 2, 2023, AV and W1 had a physical altercation in the main dining room, resulting in AV being slapped in the face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Show all 36
  • September 28, 2023: Failed to provide safe environment 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 Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about September 28, 2023, AV and W1 had a physical altercation, resulting in AV being hit on h/h hands causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • May 12, 2023: Failed to have medication available 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); 411-054-0055 (Medications and Treatments)
    State’s findings

    According to the documentation, the facility failed to have PRN bowel medication available in the facility for the Alleged Victim (AV). The failure resulted in the AV asking for the PRN bowel medication and the facility not having it available causing the AV to experience unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • April 21, 2023: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
    State’s findings

    According to the documentation, the facility failed to implement appropriate fall interventions to for the Alleged Victim (AV). The failure resulted in the AV suffering bruises and knee pain from approximately seven falls within a four-month period, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • April 4, 2023: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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

    Witness 2 (W2) has a known history of behaviors. Alleged Victim (AV) is known to have a history of invading peoples’ personal space and believes that he/she is an employee at the facility. AV’s assistance to other residents is not always welcomed by residents. On or about March 22, 2023, W2 slapped AV”s arm for invading W2’s personal space. On or about April 5, 2023, AV would not allow W2 to leave W2’s room. When AV bent down to speak to W2, W2 grabbed AV by the neck and pushed AV back. There were no additional interventions added to AV’s care plan after the event between AV and W2 on April 5, 2023. The facility failed to care plan appropriately due to AV’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • February 20, 2023: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
    Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. Between December 31, 2022, through February 19, 2023, AV has sustained eight (8) falls, some resulting in injury and one resulting in a fracture of two (2) vertebra to AV. The facility failed to provide AV with a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • January 6, 2023: 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 to provide an adequate safety plan or appropriate fall interventions for the Alleged Victim (AV). The failure resulted in the AV suffering numerous falls with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • December 31, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
    State’s findings

    According to the documentation, the facility failed to implement interventions for the Alleged Victim’s (AV) fall history. The failure resulted in the AV suffering numerous falls with injury, was not able to ambulate by themselves anymore due to fall with injury and was later admitted to hospice, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • October 28, 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); 411-054-0036 (Service Plan – General)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. Between September 8th, through December 3, 2022, AV sustained approximately 10 falls. AV sustained injuries on several of those falls. None of the falls were reported for investigation. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • October 13, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 has an unpredictable sleep scheduled and was often up late in the night and early morning hours, and due to his/her diagnoses would loudly express his/her confusions and needs for support. On or about October 13, 2022, while staff were working with another resident, AV called out for assistance while in the common area of the home. Witness 1 (W1) walked up to AV and hit AV with an open hand. On or about October 22, 2022, AV was self-ambulated close to another resident and due to confusion and AV’s vocalization being loud, the resident hit AV in the legs with a cane. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • October 5, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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) is care planned to be checked on three times during NOC shifts. AV is also care planned to be assisted by staff to change his/her briefs daily and after each incontinent episode. AV went without a brief change from 2:00 pm on or about October 4, 2022, to 6am on or about October 5, 2022. AV’s brief was heavy and soaked with urine by the time staff on the morning shift changed him/her. The facility failed to assure AV’s care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • October 4, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about October 4, 2022, AV sat down at the table with Witness 6 (W6). AV spilled his/her food and W6 started to yell at AV. AV got up and left the table, eventually AV came back to the table and W6 started yelling at AV again and then smacked AV on the hand. AV’s hand was immediately discolored with a red color and changed to purple color later. After AV was hit, he/she yelled “Ow, that hurt”, and pulled his/her hand away. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • September 30, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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) is known to wander around the unit and reach for items belonging to other residents, particularly food. Witness 1 (W1) is sensitive to someone trying to touch his/her food. On or about September 30, 2022, W1 slapped and kicked AV after AV reached for W1’s plate of food at lunch. There were similar incidents involving AV’s wandering and reaching for and touching food and other items on or about August 28th and September 3, 2022. TPS written after these two incidents only indicated to keep AV way from others, but it did not have interventions around AV’s known behaviors. The facility failed to properly care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • September 3, 2022: Failed to provide safe environment 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); 411-054-0030 (Resident Services)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about September 3, 2022, AV was involved in a resident-to-resident altercation, AV was slapped on the hand. AV was involved in a prior altercation on August 28, 2022, in which AV was grabbed and shaken by another resident. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • May 25, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about May 25, 2022, Witness 1 (W1) was sitting on a bench that is between AV and W1’s rooms. AV walked out of his/her room, picked up his/her walker and went straight to W1 and got into a resident-to-resident altercation causing AV to fall and sustained a goose egg bump on the back of their head and W1 had a scratch on his/her right hand and under his/her eye. The facility failed to provide a safe environment, which is a violation of resident right is neglect of care and constitutes abuse.

  • May 25, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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

    Alleged Victim (AV) relies on the facility for his/her care. AV and Witness 1 (W1) have a history of aggressive verbal and physical behaviors toward each other. On or about May 25, 2022, AV was sitting on a bench that is between AV’s and W1’s rooms. W1 walked out of his/her room, picked up his/her walker and went straight to AV. AV and W1 were then involved in a resident-to-resident altercation. When W1 was next to AV, he/she pushed W1 away. As a result, AV sustained scratches and W1 sustained a goose egg bum on the back of their head. The facility has not updated the care plans for both AV and W1 to clearly reflect their known behaviors. The facility failed to care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • April 24, 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 is known to have swelling in his/her legs and staff have been directed to ensure AV is in bed and not sleeping in his/her recliner, however, there is nothing noted in AV's care plan regarding this issue. On multiple occasions, AV was found with socks that were too tight and his/her legs were swollen. On or about April 18th, 21st, 25th, and 27th, 2022, AV had been left in a recliner overnight, causing swelling to AV’s feet, which is a risk of serious harm. The facility failed to properly care plan around AV’s swelling of the feet, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • April 17, 2022: Abuse: Neglect; 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); 411-054-0030 (Resident Services)
    State’s findings

    Witness #1 (W1) has a history of behaviors including physical aggression and altercations with residents and staff. On or about April 17. 2022, W1 slapped the Alleged Victim (AV) on the face, leaving a red mark. The facility failed to have interventions in place to keep other residents safe, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • March 30, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Witness 4 (W4) has a known history of violent behaviors towards staff and residents. On or about March 30, 2022, W4 an Alleged Victim (AV), were involved in a resident-to-resident altercation which led AV to sustain a fall and caused him/her an injury to the right scapula and top of the scalp. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • March 24, 2022: Failed to provide oversight and monitoring of change of condition 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); 411-054-0040 (Change of Condition and Monitoring)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. AV is at increased risk for skin breakdown and other chronic skin conditions which require daily monitoring and treatment. Between January 10th through March 6th, 2022, AV was on alert monitoring for open wound, but the alerts were closed on March 6, 2022. On or about March 24, 2022, AV was taken to the hospital where he/she was found to have state 2 wound on his/her sacral region, inflamed skin in his/her groin area, and swollen/inflamed cellulitis on his/her right leg. The facility failed to provide oversight and monitoring of change of condition, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • March 22, 2022: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
    State’s findings

    Alleged Victim (AV) relies on the facility to administer his/her medications. AV’s care plan indicated that ordering medications from Veterans Administration required a 10 to 14-day lead time to prevent AV from missing scheduled medications. The facility failed to ordering AV’s medications in a timely manner to prevent AV from missing scheduled medications for the following medications: Famotine 40mg, not dispensed February 9th through 12th, 2022, Levothyroxine 50mcg, not dispensed February 9th, through February 12th, 2022. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • March 6, 2022: Failed to provide safe environment 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)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about March 6, 2022, AV had an injury fall at the turn of the shift and was sent to the ER. AV was found facedown on the floor behind the unit kitchen. AV was on alert continually for falls. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • February 1, 2022: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
    Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0040 (Change of Condition and Monitoring)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about February 12, 2022, staff noted an open leg wound on AV’s inner right leg and some scabbing on the inner left leg. On or about March 2, 2022, AV was admitted to the ER due to wounds that appeared infected on both his/her inner right and left legs. Both legs looked swollen and had puss coming out of them. Between February 13th, through March 1, 2022, there was no mentioned of AV’s leg wounds. The facility failed to provide oversight and monitoring of change of condition, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • January 29, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Alleged Victim (AV) relies on the facility for his/her care. On or about January 29, 2022, AV was calling out for staff to help when Witness 5 (W5) went into AV’s room and attempted to help AV. When staff arrived, W5 became violent and pulled on AV’s catheter twice. W5 caused extreme pain to AV by pulling on his/her catheter causing bleeding. W5 frightened AV and caused much distress to AV. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • January 29, 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
    State’s findings

    Alleged Victim (AV) has a known history of behaviors. AV has threated harm to staff and some residents. On or about January 29, 2022, staff reported a disorderly contact from AV to law enforcement. On or about January 29, 2022, AV was involved in a resident-to-resident altercation while trying to take out a resident’s catheter. The facility failed to care plan around AV’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • January 17, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Alleged Victim (AV) is care planned to wonder to other resident’s rooms. On or about January 17, 2022, AV wandered into Witness’ (W3’s) room. AV and W3 got into a resident-to-resident altercation. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • January 17, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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)
    State’s findings

    Witness 3 (W3) is care planned to wonder to other resident’s rooms. On or about January 17, 2022, W3 wandered into Alleged Victim’s (AV’s) room. W3 and AV got into a resident-to-resident altercation resulting in W3 sustaining a swollen face and a purple eye. AV sustained skin tears to both elbows, both forearms, and scratches to his/her face. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • December 15, 2021: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 to administer his/her medications. Between October 1st, through December 16th, 2021, AV’s medication was reported unavailable, AV when without ordered medications for 75 days until a nursing audit identified the issue. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • December 11, 2021: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
    State’s findings

    On or about December 11, 2021, Witness #1 (W1) and the Alleged Victim (AV) engaged in an incident. W1 was throwing plates and bowls. W1 threw body wash on AV, getting into AV's eyes. AV was sent to the hospital for treatment to wash his/her eyes out. W1 is known to have altercations, however, his/her care plan does not have adequate interventions to avoid harm to other residents. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • December 10, 2021: Failed to provide safe environment 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); 411-054-0030 (Resident Services)
    State’s findings

    Alleged Victim (AV) relies on the facility to provide a safe environment. Witness 1 (W1) had a known history of altercations. On or about December 10, 2021, W1 and AV got into an altercation when W1 entered AV’s room. Facility staff failed to monitor W1, which resulted in the facility failing to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

  • November 26, 2021: Failed to care plan in accordance with assessment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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

    On or about November 26. 2021, Witness #6 (W6) and the Alleged Victim (AV) were engaged in an altercation. W6 is known to have behaviors and has been in multiple altercations and has been on alert charting for engaging in altercations. On the day of the incident, W6 went into AV's room and used the bathroom, AV asked W6 to leave, W6 picked AV up and threw AV to the floor, causing AV to break his/her hip, requiring surgery. The facility failed to assess and properly care plan for W6's behaviors, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

  • October 19, 2021: 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)
    State’s findings

    Witness #1 (W1) was known to have violent incidents. On or about October 19, 2021, the Alleged Victim (AV) and W1 engaged in a physical altercation. AV wandered into W1's room and used W1's bathroom, W1 got very upset and hit AV in the arm. The faciilty failed to implement interventions to keep residents safe. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

  • December 8, 2023: Failed to follow care plan 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); 411-054-0030 (Resident Services)
    State’s findings

    On or about December 08, 2023, Alleged Perpetrator 2 (AP2) failed to follow The Alleged Victim (AV) care plan. AV needs a two-person transfer along with bed positioning to safely. AP2 assisted AV without communication, resulted in AV falling over h/her bed and hitting h/h head suffering pain, and unreasonable discomfort. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse.

  • December 19, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
    Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
    State’s findings

    The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2)(b) per complaint that incidents involving a resident were not reported the local Department office.

  • December 19, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
    Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
    State’s findings

    The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re occurrence of abuse in accordance with OAR 411-054-0028(3) per complaint that known incidents did not have corresponding incident reports or internal investigations completed.

  • September 20, 2022: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
    Rules: 411-054-0036 (Service Plan – General)
    State’s findings

    The facility failed to complete service plans quarterly, which is a violation of Oregon Administrative Rules.

  • September 16, 2022: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
    State’s findings

    Alleged Victim (AV) is care planned as a two-person full assist. On or about September 16, 2022, Alleged Perpetrator 2 (AP2) attempted to transfer AV without assistance from another staff member. As a result, AV fell during the process of being transferred. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.

  • September 16, 2022: Failed to report potential or suspected abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
    Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
    State’s findings

    The facility failed to notify the local Department office of any incident of abuse or suspected abuse, including events overheard or witnessed by observation, 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.

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 36 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.

License and ownershipActive license
License type
Residential Care Facility (Memory Care endorsement)
License number
50R345
License status
Active
Licensed capacity
36

Source: Oregon state licensing records (agency listing), retrieved 2026-09-09. Licensing status is a matter of public record; it is not a quality rating.

Paying with Medicaid and other programsOn the Oregon list of Medicaid providers (2026)

On the Oregon list of Medicaid providers. Listed as Middlefield Oaks Memory Care Community under Accepts Medicaid (ODHS licensing record). (state list, as of Sep 9, 2026)

Being on the list means the community has taken part in the program. Ask whether it has a Medicaid opening now, and how many residents it serves on Medicaid.

Questions to ask on a tour10 questions picked for this community from its record

Picked for this community from its record. Ask them in person and write down the answers.

  1. The state recorded a finding in July 2026. What was it, and how was it fixed?
  2. What does the base rate include, and when did rates last go up?
  3. How many caregivers work in memory care during the day, the evening and overnight, and for how many residents?
  4. What dementia training does each caregiver get before working alone, and every year after?
  5. How do staff respond when a resident is agitated, frightened or tries to leave?
  6. How many caregivers are on duty during the day and at night?
  7. What happens if care needs increase? When would someone need to move?
  8. What fees are charged at move-in?
  9. How do you tell families about falls, illness or changes?
  10. How long have the executive director and the head of care been here?
What we checked8 public sources we searched, with dates

Every public source we searched for this community. “Nothing on record” means we found no record that matched it. A record can be missed when a name or address differs.

SourceData as ofWhat we found
Oregon Department of Human Services, Long-Term Care Licensing inspection recordsOct 15, 2026See above
Oregon Medicaid provider listSep 9, 2026See above
U.S. Department of Labor wage and hour casesOct 15, 2026Nothing on record
OSHA workplace safety inspections since 2016Oct 15, 2026Nothing on record
HUD Multifamily Properties - AssistedJul 6, 2026Nothing on record
State Veterans Homes (NASVH directory)Sep 20, 2026Nothing on record
CMS Hospice - General InformationAug 19, 2026Nothing on record
CMS Home Health Care AgenciesMay 27, 2026Nothing on record
Common questionsAnswers to 4 questions families ask
What type of care does Middlefield Oaks Memory Care Community provide?

Middlefield Oaks Memory Care Community is licensed by the state of Oregon for assisted living, memory care in Cottage Grove, Oregon. Its licensed capacity is 36 residents.

Does Lilisity rate Middlefield Oaks Memory Care Community?

No. We publish state licensing details for Middlefield Oaks Memory Care Community but no score, rating, or ranking. Only communities on the Top Communities list or with a Senior Living Alliance Excellence Award, both based on phone-verified resident and family interviews, are ranked.

How much does Middlefield Oaks Memory Care Community cost?

Assisted Living in Oregon typically starts at $4,600 to $5,800 a month. Based on 108 communities that publish prices. These are area figures, not this community's price. Middlefield Oaks Memory Care Community does not publish its prices.

How do I contact Middlefield Oaks Memory Care Community?

Visit Middlefield Oaks Memory Care Community at 1500 Village Drive, Cottage Grove, OR 97424.

Choosing assisted livingOur care guide: what to look for, what it costs, how families pay, and more questions to ask (PDF)

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How Lilisity works. The only scores or rankings Lilisity publishes are the Top Communities list and the Excellence Awards, both built from phone-verified resident and family interviews. Communities can pay Lilisity a flat monthly fee to manage their own listing: photos, prices, contact details, and receiving the inquiries families choose to send them. The fee is the same no matter how many families contact them or move in. Senior Living Alliance, which runs Lilisity, offers the same listing to its member communities as part of their membership; members pay SLA for its resident and family interview program. No community pays Lilisity per inquiry, per referral or per move-in. Payment never changes a testimonial, a rating, or the order of search results. The "Nearby Senior Living Alliance communities" box shows member communities only. How we verify testimonials · How we are paid

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