Print Violation: 00409913-AP-361025

Provider Information

Avamere at Sherwood

16500 SW CENTURY DRIVE
Sherwood, OR 97140

Date: 6/24/2025
Report number: 00409913-AP-361025
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(a), (g), (h), and (s)
Findings: On or about June 24, 2025, Alleged Perpetrator 2 (AP2) was observed physically abusing Alleged Victim (AV). Based on facility documentation and interviews, due to cognition impairment, AV has difficulty understanding and being understood. Interventions in the service plan specific to AV's needs included using a calm approach and not rushing to complete tasks. At time of incident, AP2 was observed pushing AV's legs down with force, physically using his/her legs to pin AV down and using a derogatory swear word to tell AV to stop. AP2 was also observed with his/her arms on AV's shoulders to hold AV down, preventing AV from getting up. AV suffered unreasonable discomfort as a result of AP2's actions. AV had discoloration to both arms in the days following the incident. AP2 physically abused AV by use of force that resulted in physically bodily injury other accidental means. AP2's actions is considered physical abuse which constitutes abuse. The facility failed to protect AV from physical abuse from AP2 which is a violation of Oregon Administrative Rules.