Bonaventure of Keizer Assisted Living

Last inspection

October 2, 2025

Inspections

9, 22 deficiencies cited

Substantiated abuse

12

Substantiated licensing violations

8

Regulatory actions

1

Fines assessed

$9,750.00 (12 violations)

Current owner since

March 30, 2017

License conditions and other regulatory actions

• August 14, 2023 to November 18, 2024: License Condition, Failed to use an ABST ALFCD23-00517; incident: OR0004097900
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• October 2, 2025: Kitchen, 1 deficiency 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
• November 7, 2024: Re-Licensure, 4 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Isolated
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
• June 26, 2024: Complaint Investig., 1 deficiency cited report
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated
• December 6, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 4, 2024
• May 24, 2023: Licensure Complaint, 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• January 17, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk and had a history of falls prior to moving into the facility. AV suffered a fall in November 2023. After this fall, a new intervention was put into place to remind AV to use his/her call light for assistance. AV suffered three more falls in late November and mid-December 2023, no new interventions were implemented. On December 18, 2023, AV was found on the floor in a pool of blood, it was believed that AV's blood sugar medication may have caused dizziness, leading to the facility to implement ensuring that AV eats before taking the medication. In January 2024, AV suffered three more falls without any interventions put into place. Respondent failed to ensure new and meaningful interventions were put into place to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• November 6, 2023: Failed to protect resident from financial exploitation Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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 to protect AV from theft. AV’s debit card was used for a total of $1972.98, per the police report. Per an investigation, Alleged Perpetrator 3 (AP3) and Alleged Perpetrator 4 (AP4) were seen using AV’s card, there were several transactions on AV’s card. AP3 and AP4 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 resident rights, is neglect of care and constitutes abuse.

• October 30, 2023: Failed to protect resident from financial exploitation Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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 to protect AV from theft. AV’s debit card was used for a total of $2,181.96, per the police report. Per an investigation, Alleged Perpetrator 3 (AP3), Alleged Perpetrator 4 (AP4), and Alleged Perpetrator 5 (AP5) were seen using AV’s card, there were several transactions on AV’s card. AP3, AP4 and AP5 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 resident rights, is neglect of care and constitutes abuse.

• August 1, 2023: 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. AV missed his/her drug addiction treatment pill twice on or about September 12, 2023, all three (3) doses on or about September 13 and 14, 2023, and he/she missed two (2) doses on or about September 15, 2023, and one (1) on or about September 16, 2023. It took about four (4) days for the medication issue to be resolved, however, there were no chart notes provided to demonstrate why the medication ran out or to let staff know the medication was out. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

• June 13, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) was care planned to be independent to self-transfer, per the April 26, 2023, care plan. On or about June 13, 2023, AV had an unwitnessed fall, AV was bending down to grab something out of a drawer and fell forward and then somehow backwards. As a result of the fall, AV sustained a broken bone to his/her right femur. AV needed to have surgery due to the broken femur. AV also had a fall on May 5, 2023, and had bruising on his/her shoulder and backside. There were no updates added to AV’s service plan to address the falls from May 5th and June 13, 2023. The facility failed to properly plan care and mitigate the risk of falls to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• June 26, 2024: Failed to provide inservice Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. An investigation determined this is a violation of Oregon Administrative Rules.

• March 14, 2024: 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.

• May 19, 2023: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about June 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

• January 5, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

• December 22, 2022: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The facility failed to treat the resident with dignity and respect. An investigation determined this 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 61 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.