Bonaventure of Tigard Memory Care

Last inspection

January 23, 2025

Inspections

4, 30 deficiencies cited

Substantiated abuse

20

Substantiated licensing violations

13

Regulatory actions

1

Fines assessed

$13,063.00 (20 violations)

Current owner since

February 17, 2016

License conditions and other regulatory actions

• October 19, 2022 to December 1, 2023: License Condition, Failed to use an ABST RCFCD22-01511; incident: CALMS - 00032647
  The facility failed to update the ABST (Acuity Based Staffing Tool) as required by Oregon Administrative Rules.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• January 23, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• October 25, 2023: 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 December 18, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected December 18, 2023
• October 2, 2023: Complaint Investig., 4 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 0
• September 20, 2022: Validation, 22 deficiencies cited report
  • C0000: Comment severity level 0
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern, corrected January 21, 2023
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected January 21, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected July 15, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected July 15, 2023
  Show all 24

  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected July 15, 2023
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected July 15, 2023
  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected January 21, 2023
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected January 21, 2023
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected January 21, 2023
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected January 21, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected January 21, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated, corrected January 21, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated, corrected January 21, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected January 21, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected January 21, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected July 15, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected January 21, 2023
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected January 21, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected July 15, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected January 21, 2023
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected July 15, 2023
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected January 21, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected January 21, 2023

Substantiated abuse or neglect

• August 8, 2025: 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) is a resident and under the care of the facility and has a diagnosis of dementia. AV exhibited exit-seeking behaviors; however, AV’s service plan did not address these behaviors or identify AV as an elopement risk. On or about August 8, 2025, AV eloped from the secured facility. Contractors were working in the secure are, and the back exit door was observed to be open. Staff where unaware AV had gone missing from the facility until he/she was found to be outside. Respondent failed to implement meaningful interventions for elopements, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• May 15, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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

  Witness #1 (W1) is known to become easily agitated and staff are to maintain a consistent daily routine for W1 to avoid altercations with other residents. On or about May 15, 2025, W1 was seen wandering the halls when staff heard W1 yell out. Staff observed the Alleged Victim (AV) and W1 standing in front of AV's apartment when W1 struck AV in the face, causing a cut lip. Staff failed to intervene to keep W1 from hitting AV. Respondent failed to ensure W1 was on his/her daily routine to avoid altercations, resulting in harm to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• January 19, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 January 19, 2025, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation where W1 went into AV's room and hit AV. AV suffered bleeding from the ear and was shaking in distress from the altercation. AV and W1 have had previous altercations, and staff were to monitor W1 for behaviors to avoid altercations. Respondent failed to ensure staff followed the service plan to monitor W1 to avoid altercations for resident safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• December 29, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk and is to have stand by assistance with ambulation, ensure that AV has his/ her walker or wheelchair. On December 9, 2024, AV suffered a fall where he/she broke his/her arm. The facility didn't care plan around AV's broken arm or AV's inability to properly use his/her walker. On or about December 29, 2024, AV suffered a fall near the kitchen fire door, AV suffered nose swelling, facial bruising and lost 4 of his/her teeth and required medical attention from the dentist to receive partial dentures. Respondent failed to properly care plan to ensure AV's safety from falls, and to follow the care plan to have stand by assist with ambulation. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• December 9, 2024: 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); 411-054-0030 (Resident Services)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. Witness 1 (W1) had a history of having aggressive behaviors. On or about December 9, 2024, AV and Witness 1 (W1) had an unwitnessed resident-to-resident altercation. Staff heard a loud noise and heard AV say, "ouch dammit you pushed me." Staff asked W1 what had happened, W1 said "I pushed AV" and made the motion of pushing someone. 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

• June 4, 2026: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Based on observation, record review, and interviews conducted during a site visit on 09/01/26, the facility’s failure to ensure the implementation of services was substantiated, which is a violation of Oregon Administrative Rules.

• June 4, 2026: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Based on observation, record review, and interviews conducted during a site visit on 09/01/26, the facility’s failure to ensure reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents was substantiated, which is a violation of Oregon Administrative Rules.

• August 14, 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

  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.

• August 7, 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

  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, 2025: 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

  The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

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 23 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.