Bonaventure of Gresham Assisted Living

Last inspection

September 9, 2026

Inspections

8, 30 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

12

Regulatory actions

1

Fines assessed

$1,688.00 (6 violations)

Current owner since

November 4, 2016

License conditions and other regulatory actions

• May 21, 2021 to November 4, 2021: License Condition, Failed to provide service ALFCD21-01623; incident: CALMS - 00014005
  Per re-licensure survey (DX8N11) the facility failed to provide effective administrative oversight to ensure quality care and services were rendered in the facility.
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0065 (Administrator Qualifications and Requirements); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety)

Inspections

• September 9, 2026: Re-Licensure, 1 deficiency cited report
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
• July 29, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• August 5, 2025: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Isolated
• June 18, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Isolated
  • C0450: Inspections and Investigations severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• August 12, 2024: Re-Licensure, 20 deficiencies cited report
  • C0000: Comment severity level 0
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected October 14, 2024
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected October 14, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected October 14, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected October 14, 2024
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected August 29, 2025
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Isolated, corrected April 7, 2025
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Pattern, corrected August 29, 2025
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected October 14, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 14, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected August 29, 2025
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern, corrected October 14, 2024
  • H1511: Individual Rights Settings Right to Freedom severity level 2, scope L2 Isolated, corrected October 14, 2024

Substantiated abuse or neglect

• February 28, 2025: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. Night staff are to provide routine nightly checks, three (3) to four (4) times at night. On or about February 28, 2025, at 9:30 AM, Witness 3 (W3) went to AV's room and heard a muffled sound, looked for AV and saw AV was on the bathroom floor face down. When AV was found, AV’s room smelled strongly of bowel movement and AV had diarrhea from the waist down. W3 called all staff to address the situation; staff tried to assist AV up, but AV complained of pain and staff was unable to get AV up. Staff called 911 and AV was sent to the hospital. AV stated AV was in the kitchen and had a diarrhea accident the night before. AV tried to go to the bathroom; AV fell and was unconscious. AV did not know how long AV was on the floor but estimated several hours. Hospital records estimated that AV was left on the floor in a soiled state for approximately 15 hours. The facility failed to follow the care plan by failing to conduct nightly checks on AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• August 15, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medications. On or about August 15, 2024, AV was admitted to hospice. Hospice sent the facility orders for a medication change on August 16, 2024, for (pain medication) which was to be administered 30 minutes prior to all cares, including transfer and any bedbound care. Hospice visited AV on or about August 21, 2024, and noticed the facility was not giving AV the (pain medication) prior to repositioning, which was causing AV pain. On or about August 23, 2024, hospice continued to see inconsistent (pain medication) administration and provided the facility with a medication order change. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• January 13, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medications. On or about January 13, 2024, AV was in significant amount of pain and requested pain medication throughout the day that was not provided. AV’s pain became so severe that AV requested to be transported to the hospital at 7:30 PM. While at the hospital, AV was diagnosed with a compressed fracture in AV’s spine, which was the cause of the pain. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 10, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medications. The facility ran out of AV’s anxiety medication from December 9, 2022, through December 15, 2022. The facility also ran out of AV’s blood pressure medication from December 8, 2022, through December 10, 2022. On or about December 5, 2022, AV’s PCP faxed new orders to the facility, which had changes to AV’s medications, but the anxiety and blood pressure medications were to resume as normal. The facility did not review AV’s medication inventory prior to ordering medications listed on order sent by the PCP. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 7, 2022: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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) is Care Planned to have incontinence supplies available as needed and is required to have staff check him/her periodically and see if they need to have their briefs changed. On or about December 12, 2022, Witness 2 (W2) had come in to provide care for AV. AV did not have incontinence supplies available in their room and AV had not been provided incontinence and catheter care as needed. AV is also required to be reposition every two (2) hours besides the frequent brief checks due to an open wound on their coccyx. On or about December 5, and 7, 2022, AV was not repositioned due to lack of staffing by the facility. The facility failed to provide service to AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

• March 25, 2022: Failed to answer call light in a timely manner Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 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

  On or about March 25, 2022, the Alleged Victim (AV) suffered a fall in his/her bathroom. AV pressed his/her call pendant to alert staff, however, no staff arrived. AV was on the floor of his/her bathroom for over an hour waiting for assistance. AV was not injured, however, the next day complained of pain to his/her hip and back. The facility's failure to answer the call light timely caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 25, 2025: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on 03/04/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

• August 5, 2025: Failed to cooperate with an investigation 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)
  State’s findings

  Based on interview and record review, conducted during a site visit on 08/05/25, the facility’s failure to make records available to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

• July 21, 2025: Failed to protect resident from financial exploitation 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)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. Alleged Perpetrator 2 (AP2) was being investigated for falsifying AP2's timecard when it was discovered that AP2 had been receiving money from multiple residents including AV. AP2 told AV that AP2 had not been paid by the facility and needed money. AP2 had told several residents in the facility that AP2 had not been paid and that AP2 has several children that AV needed money for. AV allowed AP2 to use AV's debit card to make a purchase. AP2 completed an online order of $67.00 using AV's debit card. AP2 failed to protect AV from financial exploitation, which is neglect of care and constitutes abuse. Respondent failed to protect AV from financial exploitation, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• July 15, 2025: Failed to protect resident from financial exploitation 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)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. Alleged Perpetrator 2 (AP2) was working in the facility. AP2 was being investigated for falsifying AP2's timecard when it was discovered that AP2 had been receiving money from multiple residents including AV. AP2 told AV that AP2 had not been paid by the facility and needed money. AP2 accepted $130.00 cash from AV. AV told AP2 that it was a loan and AV wanted to be paid back. AP2 has avoided AV since AV gave AP2 the money. AP2 completed Relias training (W1, AP2), which includes training on financial exploitation. AP2 acknowledged that AP2 knew it was wrong to take money from residents including AV, even when a resident offers money. AP2 failed to protect AV from financial exploitation, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

• July 10, 2025: Failed to provide service 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)
  State’s findings

  Based on interview and record review, conducted during a site visit on 08/05/25, the facility’s failure to ensure the implementation of services for sampled residents was substantiated, 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 72 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.