Avamere at Sherwood Assisted Living Facility

Last inspection

February 3, 2026

Inspections

6, 21 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$563.00 (2 violations)

Inspections

• February 3, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• October 30, 2025: Re-Licensure, 6 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 3, scope L3 Isolated
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
• September 24, 2025: Complaint Investig., 0 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
• January 30, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• September 27, 2023: 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 November 26, 2023
• August 22, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected January 19, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected October 23, 2022
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected January 19, 2023
  Show all 14

  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected October 23, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected October 23, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected January 19, 2023
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0615: Resident Units severity level 2, scope L2 Widespread, corrected October 23, 2022
  • C0640: Heating and Ventilation severity level 2, scope L2 Widespread, corrected October 23, 2022

Substantiated abuse or neglect

• December 1, 2021: 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

  The facility failed to provide a safe medication administration system for Alleged Victim (AV) which resulted in AV not receiving his/her medication as ordered. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 8, 2021: 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

  On or about November 8, 2021, Alleged Victim (AV) and Witness 1 (W1) engaged in sexual behavior without being able to give consent. The facility failed to properly care plan by failing to initiate interventions to respond to AV's and W1's increased behaviors. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 1, 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

  On or about February 1, 2026, Alleged Perpetrator 2 (AP2) removed dead skin from the Alleged Victim’s (AV) left foot/heel during bathing, causing AV pain and noticeable discomfort. According to facility documentation and staff interviews, AP2 reported that they were assisting AV with showering and, while helping AV dry off afterward, discovered that the bandage on AV’s left foot/heel had detached due to getting wet. AP2 stated that he/she removed the loosened bandage and observed a piece of skin approximately 1 to 2 centimeters in length hanging from the foot/heel. AP2 then cut the piece of skin off using scissors. Facility nursing staff and/or home health services are responsible for providing all medically related care including wound care. AP2 provided care and services to AV that were outside the scope of his/her job duties. AP2's actions caused AV pain and discomfort which is considered neglect of care and constitutes abuse. Additionally, the facility failed to ensure AV’s health and safety by allowing AP2 to perform tasks beyond his/her designated responsibilities. This failure represents a violation of Oregon Administrative Rules.

• September 12, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about September 12, 2023, Alleged Perpetrator 2 (AP2) administered the wrong medication to Alleged Victim (AV). Based on facility documentation and interviews, AV was observed to be completely drowsy as a result of the medication error and was taken the hospital for monitoring. AP2's actions caused AV unreasonable discomfort, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which 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 65 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.