Print Violation: 00455159-AP-407280

Provider Information

Avamere at Sherwood Assisted Living Facility

16500 SW CENTURY DRIVE
Sherwood, OR 97140

Date: 2/1/2026
Report number: 00455159-AP-407280
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide service
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
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.