Bonaventure of Albany Memory Care

Last inspection

August 4, 2025

Inspections

8, 40 deficiencies cited

Substantiated abuse

24

Substantiated licensing violations

8

Regulatory actions

1

Fines assessed

$36,627.00 (26 violations)

Current owner since

December 7, 2015

License conditions and other regulatory actions

• December 8, 2022 to March 15, 2023: License Condition, Failed to use an ABST RCFCD22-01787; incident: OR0003663101
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• August 4, 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
• April 10, 2025: Re-Licensure, 12 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0350: Administrator Qualification and Requirements severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0540: Heating and Ventilation severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated
• August 6, 2024: State Licensure, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 5, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected October 5, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 5, 2024
• July 6, 2023: State Licensure, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 6, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected September 6, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 6, 2023
• January 13, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• February 6, 2025: 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. AV is a known fall risk and has a pattern of falls. AV requires assistance with transfers/ambulation. AV requires 1-person assist with gait belt, transfer pole, slide board. Staff to encourage AV to call for 1-person standby assist for mobility/transfers. Staff to note AV may ambulate and transfer independently at times but offer standby assist/escort for fall prevention. AV has had several falls throughout the year both while out with family and in AV's prior AL apartment. Staff are to encourage AV to call for assistance with toileting and transfers in AV's apartment. Staff are to ensure that floor is clear of clutter/tripping hazards. Staff are to offer to retrieve snacks or ADL assistance during safety checks. Staff to ensure safety checks 4X per shift. On or about February 3, 2025, AV was found in his/her bathroom floor in front of the sink. On or about March 10, 2025, AV was on alert for a fall with injury with possible bruising to the right side of the forehead. On or about March 24, 205, AV was on alert for a fall with complaints of back pain and bottom pain. The facility failed to provide a safe environment to AV, which is a violation of resident rights is neglect of care and constitutes abuse.

• August 9, 2024: 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

  Witness 1 (W1) is care planned to be a one-person assist with ambulation and transfers, staff are to escort W1 while in a common area. On or about August 9, 2024, Alleged Victim (AV) was witnessed falling to the floor onto his/her back in the common are. W1 was seen grabbing the handles of AV’s wheelchair and pulled it back, causing AV to fall and sustain a skin tear to their left elbow and an abrasion to his/her back. It appears W1 was not being escorted as stated in their care plan. The facility failed to provide a safe environment for AV, leading to AV sustaining an injury, which is a violation of resident rights, is neglect of care and constitutes abuse.

• April 5, 2024: 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’s (AV’s) service plan states he/she is independent with ambulation. Between November 1, 2023, through April 24, 2024, AV had 10 documented falls, four (4) with injury. On or about April 5, 2024, AV was found on the floor next to the bed in his/her room, with AV’s head resting next to the nightstand. AV was yelling in pain and bleeding from a deep cut on his/her left finger and a large purple bruise on his/her forehead. As a result of the fall, AV was transported to the hospital for treatment. The facility failed to provide a safe environment for AV, leading to AV sustaining several falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 23, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $2,500.00; 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 December 23, 2023, AV sustained a fall in the doorway leading to AV sustaining an injury to his/her head. The facility failed to provide a safe environment for AV putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 2, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $2,500.00; 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 December 2, 2023, AV was found on his/her knees at the end of their bed with his/her wheelchair about 10 feet away. AV stated he/she was trying to get out of bed, which lead to his/her fall. The facility failed to provide a safe environment for AV putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• June 30, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

• January 25, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility’s posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

• December 1, 2025: Failed to cooperate with an investigation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

• July 4, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• October 24, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. Alleged Perpetrator 2 (AP2) had training with AV’s medication. On or about October 24, 2024, AV was to receive two units of (medication 1) for sliding scale and eight units of (medication 2). When giving AV (hormone), AP2 made a mistake and gave AV a dosage of the wrong (hormone). AP2 was supposed to give AV 30 units of long lasting but instead AP2 gave AV 30 units of fast action, along with 2 units of AV’ sliding scare (hormone). As a result of the medication, AV was transported to the hospital for care. AP2 failed to provide a safe medication system for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.

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 23 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.