Print Violation: 00417200-AP-368506

Provider Information

Cedarbrook Place Memory Care

721 NE 27TH ST
Mcminnville, OR 97128

Date: 7/30/2025
Report number: 00417200-AP-368506
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
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.
Sanction: RCFCP25-00971 $188.00 fine assessed