Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00086970
Provider Information
Middlefield Oaks Assisted Living Community
1500 VILLAGE DRIVE
Cottage Grove, OR 97424
- Provider ID
- 70A306
- Administrator
- Victoria 'Tori' Malus
- Phone
- (541) 767-0080
- exdir@middlefieldoaks.com
Violation Details
- Date
- 8/4/2025
- Report number
- CALMS - 00086970
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to perform adequate screening or assessment
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0045(1)(d)
- 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.