Bonaventure of Medford Memory Care

Last inspection

May 20, 2026

Inspections

6, 19 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

9

Regulatory actions

1

Fines assessed

$7,438.00 (9 violations)

Current owner since

November 27, 2017

License conditions and other regulatory actions

• October 24, 2023 to May 15, 2024: License Condition, Failed to use an ABST RCFCD23-01263; incident: OR0003790801
  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

• May 20, 2026: Re-Licensure, 3 deficiencies cited report
  • 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• August 7, 2024: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 6, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 6, 2024
• September 11, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 1, 2022: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 2, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 2, 2022
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected October 2, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 2, 2022
  Show all 11

  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected October 2, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 2, 2022
  • Z0155: Staff Training Requirements severity level 2, scope L2 Widespread, corrected October 2, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected October 2, 2022
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected October 2, 2022
  • Z0164: Activities severity level 2, scope L2 Isolated, corrected October 2, 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, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• July 7, 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) is at risk for falls, per AV’ care plan. On or about July 7, 2025, Witness 1 (W1) was involved in an apparent altercation with AV in which W1 may have pushed AV. As a result, AV was found with blood all over AV’s face and was transported to the hospital. Respondent failed to provide a safe environment, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• June 20, 2025: Failed to protect resident from inappropriate sexual contact 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

  Witness 1 (W1) had a known history of aggressive behaviors prior to being admitted to the facility. On or about June 11, 2025, facility staff discovered W1 attempting to have nonconsensual intercourse with Alleged Victim (AV) in W1’s room. W1 was found completely nude, erect, and holding AV from behind by AV’s waist. W1 would not permit facility staff to remove AV from W1’s room and stated that W1 was going to kill facility staff when they would not leave W1’s room. As a result of the incident, AV put AV’s self in a fetal position and started crying after the facility staff were able to interrupt W1. The facility failed to protect AV from inappropriate sexual contact and emotional abuse, which is a violation of resident rights, is neglect of care and constitutes abuse.

• February 28, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  Between February 25 to November 24, 2024, Alleged Victim (AV) sustained 12 falls. Despite all of the falls, the facility did not have or provide TSP’s that were in place to prevent future falls. AV’s safety checks remained the same in AV’s care plan and were not increased after the injury falls to help mitigate AV’s fall risk. As the result of the continuing falls, AV sustained a broken hip and broken collar bone. The facility failed to properly care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 28, 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 (AV) is care planned to be on a two-hour check. On or about December 28, 2024, AV was checked at 1:00am and his/her shower was not on. At the 5am check, AV’s shower was on, and AV’s room was humid, and warm with condensation on the walls and windows. The thermostat in AVs room read between 84 and 90 degrees. AV could not have gotten up on AVs own to turn the shower on. AV was red, clammy, and sweating. AVs body temperature was taken, and it was 103 degrees. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• July 16, 2024: Failed to assure resident was safe 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)
  State’s findings

  Alleged Victim (AV) is serviced plan to be an elopement risk and frequently stands by doors trying to go outside. On or about July 16, 2024, AV likely followed a maintenance worker and was able to leave the secured memory care building undetected. AV was found outside during a day in which the temperature was at almost 100-degree heat. The facility failed to assure a resident was safe by failing to assure AV did not eloped, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• July 30, 2026: Failed to provide service 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, conducted during an investigation on 08/05/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated, which is a violation of Oregon Administrative Rules.

• May 29, 2026: 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.

• February 18, 2026: 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.

• June 5, 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.

• May 23, 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.

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 25 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.