Inspection Reports for Middlefield Oaks Senior Living
1500 Village Dr, Cottage Grove, OR 97424 , OR, 97424
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Inspection Report
Census: 29
Capacity: 36
Deficiencies: 32
Oct 29, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited repeated deficiencies related to food sanitation, administration compliance, resident care plans, infection control, staff training, and safety measures. Some deficiencies were corrected over time, but several were repeated or ongoing, including failures in investigation and reporting of abuse, inadequate individualized resident care plans, and environmental maintenance issues.
Complaint Details
Multiple complaint investigations were conducted including on 1/17/2023, 4/14/2023, and 9/30/2022, identifying deficiencies in licensing compliance and abuse reporting.
Deficiencies (32)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and food service areas in good repair and sanitary manner with repeated observations of food spills, debris, and improper food handling |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure survey plan of correction was implemented and satisfied the Department |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities, referencing other citations |
| C0000 - Comment: Documented findings of kitchen inspections and compliance status |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs evaluating services and staff performance |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report incidents of suspected abuse and neglect promptly |
| C0242 - Resident Services: Activities: Failed to provide activity program based on individual and group interests |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, implemented, and reviewed quarterly |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor short term changes and fall prevention interventions |
| C0280 - Resident Health Services: Failed to ensure RN assessment for significant changes of condition including weight changes and fractures |
| C0295 - Infection Prevention & Control: Failed to implement effective infection control methods and universal precautions |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included resident-specific parameters |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate resident's ability and obtain physician order for self-administration |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and documented non-drug interventions |
| C0340 - Restraints and Supportive Devices: Failed to assess and instruct caregivers on use of supportive device with restraining qualities |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity based staffing tool meeting regulation requirements |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and provide required staff instruction |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire and life safety procedures within 24 hours of admission and annually |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean, in good repair, and free from unpleasant odors |
| C0530 - Housekeeping and Laundry: Failed to ensure washers had minimum rinse temperature or chemical disinfectant for soiled linens |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors had functioning alarm systems |
| Z0155 - Staff Training Requirements: Failed to ensure pre-service orientation, competency demonstration, and annual in-service training for staff |
| Z0162 - Compliance With Rules Health Care: Failed to ensure consistent provision of health services |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plan based on resident preferences and needs |
| Z0164 - Activities: Failed to develop individualized activity plans based on resident evaluations |
| Z0168 - Outside Area: Failed to ensure residents had access to enclosed, secured outdoor area allowing exit and return without staff assistance |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure perimeter fences were at least six feet in height |
| Z0176 - Resident Rooms: Failed to individually identify residents' rooms to assist recognition |
| C0010 - Licensing Complaint Investigation: Findings from complaint investigations conducted on various dates |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately notify local Department or AAA of abuse or suspected abuse incidents |
Report Facts
Inspections on page: 8
Total deficiencies: 42
Licensing violations: 10
Notices: 2
Licensed beds: 36
Resident census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director / Memory Care Director | Named in multiple findings related to kitchen sanitation, plan of correction acknowledgements, and abuse reporting |
| Staff 2 | Person In Charge / MC Resident Care Coordinator | Named in kitchen inspection findings and resident care coordination |
| Staff 3 | ED 1 | Named in quality improvement and abuse reporting findings |
| Staff 4 | ED 2 | Named in abuse reporting and facility compliance discussions |
| Staff 5 | Maintenance Director | Named in fire safety and environmental maintenance findings |
| Staff 8 | MC Care Partner | Named in staff training deficiencies |
| Staff 9 | MC Care Partner | Named in resident care observations |
| Staff 10 | MC Med Tech | Named in infection control and medication administration findings |
| Staff 11 | MC Care Partner | Named in infection control observations |
| Staff 12 | MC Care Partner | Named in staff training deficiencies |
| Staff 13 | MC Med Tech | Named in staff training deficiencies |
| Staff 16 | MC Care Partner | Named in infection control findings |
| Staff 17 | MC Med Tech | Named in infection control and medication administration findings |
| Staff 18 | Cook / MC Administrator | Named in staff training and abuse reporting findings |
| Staff 19 | RN | Named in resident care and abuse reporting findings |
| Staff 20 | Business Office Director | Named in staff training deficiencies |
| Staff 21 | MC LPN | Named in abuse reporting and medication administration findings |
| Staff 23 | Director of Operations | Named in abuse reporting and medication administration findings |
| Staff 24 | MC Activities | Named in activity plan findings |
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