Bonaventure of Salem Assisted Living

Last inspection

June 10, 2026

Inspections

10, 40 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

16

Regulatory actions

1

Fines assessed

$5,563.00 (8 violations)

Current owner since

August 22, 2012

License conditions and other regulatory actions

• April 28, 2023 to May 22, 2024: License Condition, Failed to use an ABST ALFCD23-00345; incident: OR0004023700
  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

• June 10, 2026: Re-Licensure, 10 deficiencies cited report
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • 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
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0615: Resident Units severity level 2, scope L2 Widespread
  • L0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
• June 9, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• July 15, 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
• July 24, 2024: Complaint Investig., 1 deficiency cited report
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• May 8, 2024: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 0, corrected June 13, 2024

Substantiated abuse or neglect

• July 10, 2025: Failed to provide service Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; 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); 411-054-0030 (Resident Services)
  State’s findings

  The facility was responsible for managing Alleged Victim’s (AV’s) medications. AV had major depressive disorder. Staff were to watch for signs of new or worsening depression symptoms including verbalized expressions of sadness, hopelessness, suicidal ideation, self-harm, and other symptoms. On or about May 15, 2025, AV threatened to commit suicide and AV said AV wanted to die. AV said AV wanted to “end it all.” On or about 15, 2025, AV told Witness 2 (W2) and Witness 3 (W3) that AV did not want to continue taking medications that would prolong AV’s life. AV refused medications and took medications inconsistently from May 15, 2025, to July 10, 2025. On or about July 10, 2025, AV had refused all but one of AV’s medications the previous two days. On or about July 10, 2025, AV left the facility and jumped off of an overpass. On or about July 14, 2025, AV subsequently passed away at the hospital from AV’s injuries. AV had a diagnosis of major depressive disorder. AV had active depression and mood problems. AV was under treatment for mental health related issues and was taking medication to manage AV's depression symptoms. Respondent failed by failing to provide the basic care and services of following medication management and failing to notify AV's PCP about medication refusals and suicidal ideation, causing physical harm due to AV becoming suicidal, jumping from an overpass, and dying from h/h injuries, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• December 8, 2024: 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

  Chart notes between October 21st through November 28, 2024, indicate that Alleged Victim (AV) was getting weaker and needed more help with things such as standing up. AV had two non-injury falls on October 19, 2024, and a non-injury fall the evening of December 7, 2024. AV's November 30, 2024, service plan did not reflect AV's current needs and instead noted that AV had a steady gait, had not had a fall in the last 90 days, and was not a fall risk. On or about December 8, 2024, AV sustained a fall which resulted in a fractured hip. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

• September 10, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. On or about July 4, 2024, AV fell and sustained three (3) fracture ribs and on August 19, 2024, AV once again fell and hurt his/her knee and ankle. On or about September 10, 2024, AV was found lying on the bathroom floor. As a result of this fall, AV sustained a fractured clavicle. After all of these falls, AV continued to be assessed as independent with mobility, toileting and dressing. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

• February 25, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medications. On or about February 25, 2024, Alleged Perpetrator 2 (AP2) gave AV another resident’s medication. As a result, this caused AV an adverse drug reaction which led AV to be taken to the hospital. AP 2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. 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 17, 2023: Failed to provide service 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 bedbound and completely dependent on staff for all of his/her care needs. AV has been found soaked in urine on two separate occasions. AV was first found on or about January 17, 2023, the floor was soaked, and it smelled like urine outside the door with the door closed. AV was lying in a queen size bed with no sheets on it or any pillowcases. There was a mattress cover on it, it was soaked in urine, and urine was coming down the side of the mattress. The second occasion was on or about January 30, 2023, AV was once again found with no sheets on the bed, no pillowcases and AV’s brief was soaked and on backward. As a result, AV was also found to have a rash on his/her groin area. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 14, 2022: Failed to provide service 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 needs. On or about December 7, 2022, AV needed a urine analysis done, however, urine was not collected until December 14, 2022. There were no chart notes about urine needing to be collected and alert charting was not done for a suspected UTI. AV was reported confused and weaker than usual in the charts dated December 3rd and 4th, 2022. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

• November 30, 2022: 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) has a history of falls, including fall on or about June 12, 2019, August 18, 2019, November 21, 2020, September 5, 2021, and November 24, 2022. On or about November 24, 2022, AV sustained a fall, however, this fall was not documented. AV then sustained another fall on or about November 30, 2022. AV refused a shower due to too much pain from the fall on November 30, 2022. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• April 4, 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 and complete or update and review the ABST evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• March 20, 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 and complete or update and review the ABST evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• November 16, 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

  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 and complete or update and review the ABST evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• December 31, 2024: 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 December 31, 2024, AV came to pick up his/her packages, and found remnants of those packages, with many of the items ordered missing. Alleged Perpetrator 2 (AP2) was seen on camera taking AV’s items from the packages AV ordered. 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.

• March 21, 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.

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.” 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.