Sherwood Pines Residential Care

Last inspection

January 13, 2026

Inspections

5, 15 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$500.00 (1 violation)

Current owner since

July 1, 2019

Inspections

• January 13, 2026: 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
• May 30, 2024: Complaint Investig., 2 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• February 7, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• October 3, 2023: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected December 4, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected December 4, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected December 4, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated, corrected December 4, 2024
  Show all 11

  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected December 4, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected December 4, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected December 4, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected December 4, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Isolated, corrected December 4, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected December 4, 2024
• February 1, 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 April 1, 2023

Substantiated abuse or neglect

• April 8, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  September 8, 2025, Substantive amendments to this First Amended Notice are identified: On or about April 11, 2024, Alleged Perpetrator 2 (AP2) irrigated Alleged Victim's (AV) catheter with a cleaning solution that is not intended for insertion into AV's body. Based on facility documentation, AP2 stated he/she had reservations about using a non-sterile solution in AV's irrigation, but trusted information given to him/her by Alleged Perpetrator 3 (AP3). AP2 was delegated by specialized staff for catheter care. AP2 had been instructed specifically by that staff person to go directly to delegating staff with questions related to AV's catheter. AP2 did not check AV's MAR for instructions on the catheter irrigation. Detailed information is given on the MAR, outlining very specific instructions for preparing the sterile solution to be used for this procedure. AP3 was not delegated for catheter irrigation, nor was AP3 in a role appropriate for asking procedural questions. AP2 failed to report to any appropriate staff the moment AV yelled out in pain. Per facility protocol, AP2 should have contacted AV's specialized provider and three different positions of specialized facility staff for further instructions. AP2 neglected AV by failing to follow doctor's orders, which resulted in unreasonable discomfort and increase in pain. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to ensure AV's medication treatment was properly administered as ordered and failed to provide appropriate follow-up care after the incident. Based on facility documentation and interviews, it was determined that the facility failed to promptly follow-up with retraining AP2 and AP2 continued to do AV's catheter irrigation for a couple of days after the incident before being removed from this task. As a direct result of this error, AV experienced a significant amount of pain for days after the incident, to a point that staff could not complete the irrigation as prescribed, and AV's urine was thick with debris/pink coloring. The facility's failure to both ensure staffed followed specific protocols for medication treatment administration before the incident and failure to provide an appropriate response after the incident caused AV pain and unreasonable discomfort lasting more than 24 hours, is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP3.

Substantiated licensing violations

• April 29, 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.

• April 7, 2024: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to ensure the implementation of services. Based on observation, interview, and record review, conducted during a site visit on 05/30/24, it was confirmed the facility failed to ensure the implementation of services for 3 of 4 sampled residents (#1's, 2, 3, and 4) whose records were reviewed. An investigation determined no licensing violation or abuse occurred.

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 16 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.