Print Violation: 00458858-AP-411178

Provider Information

Bonaventure of Gresham Memory Care

22514 SE STARK STREET
Gresham, OR 97030

Date: 2/19/2026
Report number: 00458858-AP-411178
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to protect resident from mental or emotional abuse
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
Findings: Alleged Victim (AV) relies on the facility for his/her care. On the evening of February 18, 2026, Witness 3 (W3) walked in on Alleged Perpetrator 2 (AP2) taking a picture of Alleged Perpetrator 3 (AP3) changing AV's incontinence brief. AP3 was pulling AV's incontinence brief back and was making "gagging" faces while pointing and laughing. AV had been sick and had loose stool. The picture showed AV's bare legs, part of AV's bottom and AV's face with the incontinence brief and feces. AV looked sick and "miserable" in the picture. W3 found the conduct of AP2 and AP3 towards AV to be humiliating and degrading. AP2 and AP3 confirmed a photograph was taken of AP3 in AV's room of AP3 making "faces" while changing AV's incontinence brief. AP2 and AP3 failed to protect AV from emotional abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from emotional abuse, which is a violation of Oregon Administrative Rules.