Cedarbrook Place Senior Living

    721 NE 27th St, McMinnville, OR 97128
    • Independent Living
    • Assisted Living

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    Reviews

    4.17·(30)

    Overall rating

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    4. 2
    5. 1
    • Care

      3.6
    • Staff

      3.9
    • Meals

      2.5
    • Amenities

      4.5
    • Value

      1.5

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    Location

    Cedarbrook Place Senior Living is located at 721 NE 27th St, McMinnville, OR, 97128.

    People often ask...

    Cedarbrook Place Senior Living offers independent living and assisted living.

    There are 23 photos of Cedarbrook Place Senior Living on Mirador.

    The full address for this community is 721 NE 27th St, McMinnville, OR 97128.

    No, Cedarbrook Place Senior Living does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number5MA130
    StatusActive
    Facility typeResidential Care Facility
    Capacity15 residents
    LicenseeVOP Cedarbrook Place, LLC
    EffectiveJune 11th, 1998
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    83

    Reports

    0

    Type A Citations

    0

    Type B Citations

    1

    Complaints

    16

    Years

    06 Jun 2026Inspection
    Found a deficiency related to in-service training and assuring the Alleged Victim's rights; the sexual abuse claim did not involve abuse.
    • Licensing—Failed to provide inservice
    04 Jun 2026Inspection
    Investigated and found deficiencies related to staff in-service training and adherence to the care plan, which created a risk of harm and indicated neglect of care.
    • Licensing—Failed to provide inservice
    09 Apr 2026Change of Owner
    Identified deficiencies in service planning, condition monitoring, health services, staffing data, and fire safety, showing incomplete plans, missing RN assessments, inadequate wound care monitoring, inaccurate staffing data, and insufficient resident fire safety instruction.
    • Deficiency—Service Plan: General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Acuity Based Staffing Tool - ABST Time
    • Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training for Residents
    • Deficiency—Inspections and Investigation: Insp Interval
    10 Mar 2026Change of Owner
    Identified multiple deficiencies in acuity-based staffing, fire safety, administration, and staff training, including inaccurate ABST minutes and incomplete ABST updates, irregular fire drills, environmental concerns, and missing pre-service dementia training.
    • Deficiency—Acuity Based Staffing Tool - ABST Time
    • Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Doors, Walls, Elevators, Odors
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    09 Mar 2026Kitchen
    Identified extensive cleanliness and repair issues in the kitchen that did not meet sanitation requirements. The findings showed surfaces, equipment, and areas were dirty and in disrepair.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    09 Mar 2026Kitchen
    Found deficiencies in kitchen sanitation and administration compliance, with extensive cleaning and repair needs and policy gaps noted.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    21 Nov 2025Abuse: Neglect
    Investigated and found failures to plan care and address fall risk, resulting in injury.
    • Abuse—Failed to properly plan care
    08 Nov 2025Inspection
    Investigated and found a staff member failed to administer medications as ordered, causing a burning sensation and discomfort for the resident.
    • Licensing—Failed to provide inservice
    08 Nov 2025Inspection
    Found neglect and abuse occurred when a staff member administered another resident's medication to the resident, risking serious harm, and failed to protect the resident or ensure proper administration as ordered.
    • Licensing—Failed to provide inservice
    19 Oct 2025Abuse: Neglect
    Investigated found a failure to provide a safe environment and to administer medications as ordered, resulting in a fall with injury and inadequate care planning.
    • Abuse—Failed to provide safe environment
    18 Sept 2025Abuse: Neglect
    Investigated a failure to administer prescribed pain medication over several days, resulting in unnecessary discomfort; a $250 fine was assessed.
    • Abuse—Failed to administer ordered medication
    19 Aug 2025Kitchen
    Identified violations of food sanitation rules and administration compliance.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    19 Aug 2025Kitchen
    Identified multiple deficiencies in kitchen sanitation and food storage that did not meet required rules.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    11 Aug 2025Abuse: Neglect
    Determined there was inadequate care planning to address repeated falls, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    30 Jul 2025Abuse: Neglect
    Concluded that care planning failed to prevent a resident from entering another resident's room, which led to a physical altercation. There were no documented interventions to stop wandering into the room.
    • Abuse—Failed to provide safe environment
    05 Jul 2025Abuse: Neglect
    Investigated and found that inadequate medication reordering left a resident without a blood thinner for a day, creating a risk of harm.
    • Abuse—Failed to provide a safe medication administration system
    05 Jul 2025Abuse: Neglect
    Found neglect and abuse due to failure to properly care plan for increased weakness, leading to falls and hospitalization.
    • Abuse—Failed to follow care plan
    07 May 2025Licensure
    Identified widespread deficiencies in resident evaluations, service plans, change-of-condition monitoring, medication practices, staffing, training, fire safety training for residents, and building upkeep.
    • Deficiency—Resident Move-in & Evaluation: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Service Plan: Service Planning Team
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Resident Right to Refuse
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Annual and Biennial Inservice for All Staff
    • Deficiency—Fire and Life Safety: Training for Residents
    • Deficiency—General Building: Doors-Walls, Cleanable
    03 May 2025Abuse: Neglect
    Investigated a complaint and found the care plan lacked interventions for a resident's aggression, resulting in emotional distress to another resident and constituting abuse and neglect.
    • Abuse—Failed to properly plan care
    19 Apr 2025Abuse: Neglect
    Found inadequate care planning and interventions to manage aggressive behavior between residents, leading to repeated resident-to-resident altercations.
    • Abuse—Failed to properly plan care
    10 Oct 2024Abuse: Neglect
    Investigated the allegation and found that ordered diuretic medication was not administered for 11 days, leading to hospitalization of the recipient.
    • Abuse—Failed to administer ordered medication
    01 Aug 2024Inspection
    Cited a licensing violation for failing to provide a safe environment by not complying with weekly vaccination reporting requirements for vaccinated individuals, residents, and staff; a $250 fine was assessed.
    • Licensing—Failed to provide safe environment
    25 Jul 2024Licensure
    Identified deficiencies in meals service and sanitation, later found substantial compliance on follow-up.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    25 Jul 2024Licensure
    Found sanitation deficiencies in the kitchen during the initial visit; a follow-up confirmed substantial compliance with food safety rules.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    28 Apr 2024Abuse: Neglect
    Investigated a fall-related case and found failure to properly plan fall interventions, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    16 Mar 2024Abuse: Neglect
    Concluded neglect and abuse from failing to follow the care plan, leading to multiple falls and a hip fracture.
    • Abuse—Failed to follow care plan
    16 Feb 2024Inspection
    Found a staff member failed to provide a safe medication administration system, administering another resident’s medication to a resident and causing discomfort.
    • Licensing—Failed to provide a safe medication administration system
    06 Dec 2023License Condition
    Found that an Acuity Based Staffing Tool was not used as required.
    • Regulatory Action—Failed to use an ABST
    02 Oct 2023Complaint
    Identified failure to fully implement an acuity-based staffing tool for three sampled residents, with incomplete ADL entries and outdated updates.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Infection Prevention & Control
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity-Based Staffing Tool
    05 Sept 2023Inspection
    Identified failure to establish and maintain infection prevention and control protocols, resulting in an unsafe and unsanitary environment.
    • Licensing—Failed to provide service
    21 Jun 2023Licensure
    Identified kitchen sanitation deficiencies on the initial visit. Subsequent follow-up found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    21 Jun 2023Licensure
    Found sanitation lapses in the kitchen and administration compliance concerns during two visits. The findings included improper food storage, uncovered trash, and gaps in adherence to food sanitation rules.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    25 May 2023Abuse: Neglect
    Investigated a complaint and found care planning failed to address a resident's fall history, resulting in an unwitnessed fall and injury; a $250 fine was assessed.
    • Abuse—Failed to properly plan care
    19 May 2023Inspection
    Found a licensing violation for failing to submit timely or adequate staffing documentation, including weekly vaccination reporting, for 30 days in April 2023.
    • Licensing—Failed to submit timely or adequate staffing documentation
    18 May 2023Abuse: Neglect
    Investigated a complaint alleging neglect and abuse; found that a resident experienced multiple self-transfer falls and long delays for staff assistance, with call lights often not answered promptly.
    • Abuse—Failed to provide service
    19 Sept 2022Validation
    Identified multiple deficiencies in incident investigations, service planning, psychotropic medication documentation, and resident activities, indicating failures to meet licensing requirements.
    • Deficiency—Comment
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—Administration Compliance
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Activities
    07 Sept 2022Inspection
    Investigated and found that a resident experienced financial exploitation and neglect, with items taken and meds missing.
    • Licensing—Failed to protect resident from financial exploitation
    07 Jul 2022Abuse: Neglect
    Investigated and found failure to administer medication as ordered, resulting in pain and discomfort; identified violations for neglect and abuse.
    • Abuse—Failed to administer medication as ordered
    22 May 2022Abuse: Neglect
    Found failures to follow the service plan for routine and overnight checks, causing the resident discomfort and constituting neglect with a civil penalty assessed.
    • Abuse—Failed to follow care plan
    16 Mar 2022Validation
    Identified deficiencies in kitchen sanitation, service planning, fall monitoring, psychotropic medication practices, staff training, and building maintenance. Violations cited across multiple areas for the findings observed during the survey and follow-up visit.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Service Plan: General
    • Deficiency—Service Plan: Service Planning Team
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Training Within 30 Days: Direct Care Staff
    • Deficiency—Annual and Biennial Inservice For All Staff
    • Deficiency—General Building: Doors-Walls, Cleanable
    19 Feb 2022Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe medication administration system, leading to a resident receiving a held medication and risking serious harm.
    • Abuse—Failed to provide a safe medication administration system
    07 Jan 2022Abuse: Neglect
    Found deficiencies in care planning and interventions for a resident's fall history, leading to an unwitnessed fall with head injury and resulting pain and discomfort.
    • Abuse—Failed to properly plan care
    15 Aug 2021Abuse: Neglect
    Investigated and found abuse/neglect due to failure to provide a safe environment, resulting in loss of dignity and unreasonable discomfort; a fine was assessed.
    • Abuse—Failed to provide safe environment
    19 Jun 2021Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment that put a resident at risk. A $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    25 May 2021Abuse: Neglect
    Found that a resident did not have a safe environment, constituting neglect and abuse, and assessed a $250 fine.
    • Abuse—Failed to provide safe environment
    26 Mar 2021Inspection
    Verified resident rights were not assured.
    • Licensing—Failed to assure resident rights
    26 Mar 2021Inspection
    Investigated the staffing allegation and confirmed inadequate staffing.
    • Licensing—Failed to provide appropriate staffing
    12 Mar 2021Inspection
    Investigated and identified violations for failing to follow a care plan for arranging lab services, which led to a hospital transfer and patient discomfort.
    • Licensing—Failed to provide service
    23 Nov 2020Inspection
    Investigated the allegation of infection-control failures and found COVID-19 precautions were not followed, with staff not wearing face shields on the night shift.
    • Licensing—Failed to provide infection control
    09 Oct 2020Abuse: Neglect
    Investigated allegations found neglect related to failure to plan care after a history of falls, resulting in multiple unwitnessed falls and discomfort.
    • Abuse—Failed to properly plan care
    23 Mar 2020Abuse: Neglect
    Investigated a complaint about care planning after a change in condition; found neglect and abuse resulting in pain and discomfort from maggot-infested condition. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    27 Jan 2020Inspection
    Investigated a nursing delegation allegation and concluded a violation occurred.
    • Licensing—Failed to comply with nursing delegation requirement
    27 Jan 2020Inspection
    Determined that the allegation of failing to report potential or suspected abuse was substantiated.
    • Licensing—Failed to report potential or suspected abuse
    17 Jul 2019Abuse: Neglect
    Investigated a neglect allegation and identified failure to provide basic care, resulting in a resident fall with injuries.
    • Abuse—Failed to follow care plan
    16 Jun 2019Abuse: Neglect
    Investigated abuse allegation and found neglect due to failure to provide basic care and supervision, resulting in risk of harm to a resident.
    • Abuse—Failed to assure resident was safe
    04 Jun 2019Inspection
    Identified a supervision deficiency that created an unsafe environment and led to one person harming another.
    • Licensing—Failed to provide safe environment
    04 Jan 2019Abuse: Neglect
    Investigated and found neglect resulting in physical harm due to failure to provide basic care.
    • Abuse—Failed to follow care plan
    02 Nov 2017Abuse: Financial abuse
    Investigated an allegation of financial exploitation and concluded there was a failure to protect a resident from exploitation, along with a failure to maintain a safe environment that led to theft of residents' belongings.
    • Abuse—Failed to protect resident from financial exploitation
    12 Oct 2017Inspection
    Determined that there was a failure to assess and intervene, resulting in a noninjury residenttoresident altercation.
    • Licensing—Failed to provide safe environment
    02 May 2017Abuse: Neglect
    Found neglect resulting in several days of eye irritation after the wrong medication was placed in the resident's right eye.
    • Abuse—Failed to administer medication as ordered
    05 Feb 2017Abuse: Neglect
    Determined residents were not protected from a resident-to-resident altercation, which caused a skin tear.
    • Abuse—Failed to provide safe environment
    27 Jan 2017Abuse: Verbal/Mental abuse
    Determined that a resident was not protected from verbal abuse.
    • Abuse—Failed to protect resident from verbal abuse
    27 Dec 2016Abuse: Financial abuse
    Investigated a financial exploitation allegation and found a security failure allowed cash to be stolen.
    • Abuse—Failed to protect resident from financial exploitation
    15 Oct 2016Abuse: Neglect
    Found a failure to provide a safe environment that allowed a resident-to-resident altercation.
    • Abuse—Failed to provide safe environment
    28 Sept 2016Abuse: Neglect
    Identified neglect due to failure to monitor change of condition and to obtain timely medical care after an injury, causing significant pain.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    11 Aug 2016Abuse: Neglect
    Concluded neglect occurred due to failure to intervene when a resident's condition changed, involving moderate harm or potential for serious harm.
    • Abuse—Failed to intervene when resident's condition changed
    18 Feb 2016Abuse: Neglect
    Determined the allegation of failing to perform adequate screening or assessment substantiated.
    • Abuse—Failed to perform adequate screening or assessment
    29 Sept 2015Abuse: Neglect
    Investigated a complaint alleging neglect and identified a failure to provide a safe environment, exposing residents to physical aggression.
    • Abuse—Failed to provide safe environment
    06 Aug 2015Inspection
    Investigated and found a failure to provide a safe environment and appropriate care.
    • Licensing—Failed to provide safe environment
    31 Mar 2015Abuse: Neglect
    Determined failure to properly assess and intervene when the resident's condition changed.
    • Abuse—Failed to intervene when resident's condition changed
    02 Sept 2014Abuse: Neglect
    Determined a deficiency occurred due to failure to intervene when a resident's condition changed, resulting in an injury.
    • Abuse—Failed to intervene when resident's condition changed
    28 Jul 2014Abuse: Financial abuse
    Investigated and found a failure to provide a secure environment.
    • Abuse—Failed to provide safe environment
    06 Jun 2014Inspection
    Found an inadequate medication administration system that posed a risk of harm.
    • Licensing—Failed to provide a safe medication administration system
    12 Aug 2013Inspection
    Concluded there were deficiencies in the medication system that could harm residents due to failure to provide a safe administration process.
    • Licensing—Failed to provide a safe medication administration system
    07 Mar 2013Inspection
    Investigated and found safety deficiencies related to failing to address a resident's behavior and keep two residents safe.
    • Licensing—Failed to address resident's behavior
    13 Feb 2013Inspection
    Found deficiencies related to failure to properly plan care and address a resident's behavior change.
    • Licensing—Failed to properly plan care
    03 Oct 2012Inspection
    Investigated the allegation and found a violation for failing to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    05 Jun 2012Abuse: Neglect
    Found a failure to provide a safe environment and a $300 fine was assessed.
    • Abuse—Failed to follow care plan
    07 Oct 2011Inspection
    Investigated a complaint and found a safe medication administration system was not provided.
    • Licensing—Failed to provide a safe medication administration system
    30 Jun 2011Abuse: Financial abuse
    Investigated and found an inadequate medication administration system.
    • Abuse—Failed to provide a safe medication administration system
    30 Jun 2011Inspection
    Found a deficiency in safety due to failure to provide a safe environment.
    • Licensing—Failed to assure resident rights
    29 Apr 2011Abuse: Neglect
    Determined that appropriate medical care was not provided as ordered, and assessed a $400 fine.
    • Abuse—Failed to provide medical treatment as ordered
    10 Jun 2010Abuse: Financial abuse
    Investigated a financial abuse allegation and found that a secure environment was not provided.
    • Abuse—Failed to provide a safe medication administration system

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