Bonaventure of Medford Assisted Living

Last inspection

May 21, 2026

Inspections

7, 19 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$6,125.00 (7 violations)

Current owner since

November 27, 2017

Inspections

• May 21, 2026: Re-Licensure, 4 deficiencies cited report
  • 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
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
• August 7, 2024: 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 October 6, 2024
• November 16, 2023: Complaint Investig., 1 deficiency cited report
  • C0380: Involuntary Move-Out Criteria severity level 2, scope L2 Isolated
• September 11, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 1, 2022: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected November 15, 2022
  Show all 12

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected November 15, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected November 15, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated, corrected November 15, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected November 15, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected November 15, 2022
• July 26, 2022: 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
• July 13, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• August 2, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) has a known history of falls. On or about August 5, 2025, AV had an unwitnessed fall while trying to get out of bed to use the bathroom when AV slipped and hit AV’s head on the bed frame before landing on AV’s bottom. As a result of the falls, AV was diagnosed with spinal fractures. The facility failed to update AV’s Service Plan to document and properly plan for AV’s fall risk, which is a violation of resident rights, is neglect of care and constitutes abuse.

• January 8, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 independent in ambulation without assistive devices. AV did not have a pattern of falls and AV was not a fall risk. On January 8, 2025, AV was entering the lobby area and AV tripped over a vacuum power cord which resulted in AV falling face first on to the floor. As a result, AV ended up with a swollen left eye and a nosebleed and was sent to the hospital for evaluation. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• September 3, 2024: Failed to provide safe environment 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’s (AV’s) care plan states AV does not require assistance with transfer/ambulation. AV has sustained falls on or about July 20th, 29th, 30th, and August 29th, 2024, and a second fall on August 29, 2024. On or about August 30, 2024, AV complained to staff of soreness on AV’s buttocks from the first fall that occurred on August 29, 2024. On or about September 3, 2024, AV was transported to the hospital for an evaluation due to a seizer event and later returned that day to the facility. Later on, September 3, 2024, AV was again transported to the hospital due to consistent pain on his/her left side. AV was diagnosed with a fractured to the hip during the second ER visit. The facility failed to assure AV was provided a safe environment, which resulted in a fracture hip, which is a violation of resident rights, is neglect of care and constitutes abuse.

• July 22, 2024: Failed to provide safe environment 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) has a known history of falls and has fallen on or about March 12th, 23rd, April 1st, 6th, and July 14, 2024. On or about July 22, 2024, AV experienced another fall while at the facility. The next day, AV was crying and stated AV’s chest was hurting the day after AV fell. As a result of the fall, AV was transported to the hospital and was diagnosed with a fractured sternum and a pleural infusion. The facility failed to provide a safe environment for AV leading to AV sustaining many falls and a fracture, which is a violation of resident rights, is neglect of care and constitutes abuse.

• July 19, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) had cognitive impairment related to dementia/Alzheimer’s. AV’s care plan dated June 8, 2024, states he/she is not at risk for elopement or leaving facility. However, it is documented that AV has a known history of elopement and exit seeking behaviors. On or about July 19, 2024, AV eloped from the facility. AV was found confused in a park and was unable to remember how to get home. The facility failed to properly care plan and document AV’s elopement behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

• May 17, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim’s (AV’s) care plan states that AV does not require assistance with transfer or ambulation. On or about April 20, 2024, AV sustained a fall from his/her bed. On or about May 16, 2024, AV’s hospice ordered a hospital bed for AV, with a delivery date of May 23, 2024, due to AV’s declining health. The facility was informed of AV’s decline in health and his/her change in ambulation. On or about May 18, 2024, AV slipped out of his/her bed while AV was trying to stand up and fell to the floor. On or about May 20, 2024, staff found AV face down on the floor of AV’s bedroom up against AV’s metal bed frame. As a result, AV sustained a skin injury due to the fall. If the facility has a fall incident, the facility will complete an occurrence report, alert charting, and complete a temporary care plan (TCP), however, no TCPs were provided by the facility that documented AV’s fall incidents from May 18th and 20th, 2024. The facility failed to properly plan care around AV’s known changed in ambulation condition and by not properly following up with a TCP, which is a violation of resident rights, is neglect of care and constitutes abuse.

• November 26, 2021: Failed to properly plan care Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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 facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls between September 27, 2021, and December 05, 2021, some resulting in injury including but not limited to head injury, broken bones, and abrasions. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 17, 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. On or about October 17, 2025, AV handed Witness 1 (W1) AV's wallet to pay $80 for services from [beauty specialist] with AV's money. There were 3- $100 bills, some $20 bills and a $5 bill in AV's wallet that equaled $400. AV went to the facility's "Happy Hour" at 3:00pm, and AV left AV's wallet in AV's room with W1. AVs walled went missing but was later found under a pillow and the $400 was missing from AV’s wallet. It is believed that an unknown Alleged Perpetrator 2 (AP2) may have stolen AV’s money, 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 28, 2025: Failed to protect resident from financial exploitation Licensing Violation; Level 3 - Moderate harm or potential for serious 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) came into AV’s room while AV was sleeping to access AV’s safe and take out AV’s cash on more than one occasion. On or about July 28, 2025, AP2 was caught on video surveillance going through AV’s safe. AP2 admits to taking cash out of AV’s safe for AP2’s personal use and was arrested and charged with stealing $1,340.00 in cash from AV’s safe. 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.

• April 27, 2023: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0080 (Involuntary Move-out Criteria)
  State’s findings

  The facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge per complaint that the facility failed to assess the resident within 24 hours of discharge, which is a violation of Oregon Administrative Rules.

• January 13, 2023: 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.

• July 26, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Facility failure to provide reasonable precautions against any condition that may threaten the health, safety, or welfare of residents per OAR 411-054-0025(4) visitors are not being screened in.

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 69 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.