Shore Pines Senior Living

The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, the AV was not administered their medications as ordered on multiple occasions between approximately November 11, 2024 and January 4, 2025, resulting in repeated unreasonable discomfort. The facility failed to administer the AV’s medication as ordered, which is a violation of resident’s rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about January 21, 2025, the AV was not administered multiple medications as ordered in November 2024, including medications for blood pressure and anxiety, placing the AV at risk and causing them unreasonable discomfort. The facility failed to administer AV’s medication as ordered, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment. Witness 1 (W1) has a know history of verbal abuse and aggression towards others. W1's care plan lacks interventions related to their verbal abuse of others. According to an investigation, on or about December 25, 2024, W1 verbally abused the AV, calling them derogatory names and causing emotional harm. The facility failed to appropriately care plan for W1 to ensure a safe environment for the AV, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

Alleged Victim (AV) is care planned to self-administer his/her insulin; however, staff must prepare insulin and watch administration. On or about June 15, 2024, a medication audit at the facility discovered AV’s medication to be expired. As a result, AV went through the weekend without his/her medication. Per AV’s PCP, AV not receiving the prescribed medication posed a serious risk of ham. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 14, 2023, at about 8:30am, Witness 1 (W1) went to AV’s room and knocked on his/her door, AV opened the door and W1 attacked AV. As a result of the altercation W1 ended up cutting AV’s wrist and then chocking AV with his/her hands around AV’s neck. Staff found W1 in AV’s room with his/her hands around AV’s neck chocking him/her. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a high fall risk per AV’s care plan, but no interventions or directions are listed. On or about August 24, 2023, AV was found in front of the building on the ground. AV had two prior falls, one on May 26, 2023, and the other on July 10, 22023. As a result of the most recent fall, AV sustained an injury. The facility failed to properly plan care around AV’s known history of falls which puts AV in risk of harm and is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about July 26, 2023, AV was found face down on the floor, blood was observed dripping from a wound that occurred the day before. AV was incoherent and was transported to the ER. AV had a prior fall on July 25, 2023, the fall occurred 10 hours prior to the current fall from July 26, 2023. The facility failed to provide a safe environment for AV by failing provide proper supervision and service to AV, resulting in falls and injuries to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim is known to be a high fall risk resident. Per the care plan, staff are to be always next to AV when AV is transferring and ambulating. On or about June 21, 2023, AV had an unwitnessed fall. Staff heard the fall and found AV on the floor in the dining area. The facility failed to follow the care plan around been next to AV to avoid AV from sustaining falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim is known to be a high fall risk resident. Per the care plan, staff are to be always next to AV when AV is transferring and ambulating. On or about July 8, 2023, AV sustained a second fall within the last 30 days. Staff found AV in the floor in the common area. The facility failed to follow the care plan around been next to AV to avoid AV from sustaining falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. W1 has been in prior resident-to-resident altercations with Alleged Victim (AV). On or about March 19, 2023, W1 rammed into AV’s scooter with their own. AV then went to report incident to staff and as AV was reporting the incident, W1 came and got in front of AV’s scooter and began to yell to AV to “shut up” and that W1 was going to “rip AV’s head off”. The facility failed to provide a safe environment for AV, which puts AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned as high fall risk. Staff are to help ensure safety in AV’s room, helping to prevent any falls from occurring. On or about November 1, 2022, AV had stated that they were standing up at the toilet and ended up falling on the floor and the wall. On or about January 30, 2023, AV sustained a fall and received a black eye. AV fell and hit his/her face on the toilet. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 18, 2023, AV was coming back into the facility when Witness 1 (W1) met AV in the front door where W1 then hit AV over the back of the head with a golf club. As a result of the altercation, AV stated that he/she had tenderness and pain. W1 stated he/she instinctually waited for AV to hit him/her. As a result, this put AV in risk of harm. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Between November 5, 2022, through December 14, 2022, Witness 1 (W1) had six (6) behavior incidents. On or about January 6, 2023, Alleged Victim (AV) was in the family room of the facility when W1 came in and rammed into AV with his/her wheelchair pushing AV into the fireplace. W1 stated that he/she had rammed AV as payback for AV knocking his/her hat off and that AV still had three more injuries coming, W1 also stated, “I will get AV, next time I hit him/her, he/she will be dead with one punch.” The facility failed to provide a safe environment for AV by not supervising W1 appropriately, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has been left on several occasions sitting in their feces and urine and not cleaning them up. On or about December 16, 2022, AV was sent to the hospital covered in bowel movement (BM) and urine. When AV goes to the bathroom by themselves and get covered in BM, they will then scratch their legs causing their BM to get into their scratched area and getting infected. AV is not being showered correctly and AV’s room is not being kept clean. The facility failed to provide service to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to have aggressive, disruptive behaviors. On or about November 17, 2022, W1 was using their wheelchair and rammed into Alleged Victim (AV) who was also in a wheelchair. W1 grabbed AV’s right arm and wrist using both of their hands and bent AV’s arm back causing bruising and a scratch on AV's hand that was bleeding. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of aggressive and violent behaviors. On or about November 2, 2022, per a facility video surveillance, W1 is seen outside his/her apartment door in his/her wheelchair as if he/she is going into it. Alleged Victim (AV) is seen coming down the hall in his/her wheelchair and passes by W1 and goes to his/her apartment door. As soon as AV passes by W1, W1 starts to follow AV and once he/she gets to AV, he/she bumps into AV’s wheelchair. W1 then grabs AV’s right arm and lifts his/her own left arm as if to hit AV. W1 then uses his/her two arms to grab and twist AV’s right arm. As a result of the altercation, AV sustained a bruise on their hand. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. AV did not receive his/her narcotic pain medication on three (3) occasions in July 2022, once in August 2022 and three occasions in September 2022. On or about July 31, 2022, AV went to the hospital due to chest pain and possible withdrawal symptoms from not having his/her narcotics medications. There was no physician communication provided regarding AV’s medication in July and August 2022. AV did not receive his/her blood thinner medication on or about August 1st, 30th or 31st, 2022, for reasons unknown, according to the MAR. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to received assistance with medication, and staff were to administer all medications as scheduled. AV was out of his/her anti-depressant medication from August 10, 2022, through August 17, 2022. AV had experienced a loss prior to the medication not being available to him/her and so AV was not coping well. The facility was to reorder resident’s medication between 7-10 days before running out, however, there was no information provided showing the medication was order, or that anyone followed up on any order to make sure AV did not run out of their medications. The facility failed provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. AV has been on their mood medication since they moved into the facility and had a dosage adjustment of their thyroid medication in March 2022. It was discovered that AV had not been receiving their prescribed thyroid or mood mediations for an unknown period of time. In mid-June 2022, AV was discovered to be out of four (4) medications that appeared not to have been transcribed over into the new system, resulting in the orders not being received by the pharmacy. It is unclear how long AV had been without medications, but it is estimated it was between May 1, 2022, thru June 16, 2022, putting AV in risk of harm due to the missed medications. A bucket with AV’s medication list was discovered under a desk recently vacated by Alleged Perpetrator 2 (AP2). AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. AV has a history of swelling in the legs and has reported pain due to this swelling. AV receives a PRN pain medication to aid in pain management. The facility had a computer system switchover as a result of ownership change and so staff were unable to access weights for multiple days for AV. Staff were unable to confirm if AV had received his/her proper medication or not, and the facility did not have access to and was unable to provide request for MAR documentation. As a result of this, AV’s legs swelled up and required a doctor’s visit. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe environment by not providing appropriate supervision and staff support regarding known behaviors between the Alleged Victim (AV) and Witness 1 (W1). W1 threw coffee on AV approximately three times, in about one week. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the care plan by not provide appropriate services according to the Alleged Victim’s (AV) needs and wound care. The failure resulted in AV suffering further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of being belligerent, intoxicated and having inappropriate language and behaviors towards staff and other residents. W1 has several behavioral plans in place with repeat interventions that are not effective in preventing AV behaviors towards other residents. On or about December 02, W1 was intoxicated, and made inappropriate comments towards AV, which made AV cry. The facility failed to appropriately care plan and implement reasonable interventions to address W1’s behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of being belligerent/intoxicated/and having inappropriate language and behaviors towards staff and other residents. W1 has several behavioral plans in place with repeat interventions that are not effective in preventing W1 behaviors towards other residents. On or about December 01, 2021, W1 was intoxicated, belligerent and using foul language towards Alleged Victim, which caused emotional harm to AV. The facility failed to appropriately care plan and implement reasonable interventions to address W1 behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim has a history of being belligerent/intoxicated/and having inappropriate language and behaviors towards staff and other residents. AV has several behavioral plans in place with repeat interventions that are not effective in preventing AV behaviors towards other residents. On or about December 01, 2021, AV was intoxicated, belligerent and using foul language towards other residents. Witness 1 (W1), and AV got into a verbal altercation, leading W1 to spray AV in the face with water. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to have Alleged Victims (AV) pain medication available, causing unnecessary pain and discomfort to AV. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have assistance with toileting and transferring. AV has history of refusing assistance, toileting, and changing. AV was observed to be soiled, and bed/linens soiled. The facility failed to provide necessary interventions and care planning regarding AV refusing care, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of resident-to-resident altercations, agitation and aggressive behaviors towards other residents and members of the care team. On or about November 11, 2021, W1 had aggressive behavior towards Alleged Victim (AV), which lead to a resident-to-resident altercation. W1 approached (AV), shouted at AV and pushed AV causing AV to fall to the ground. The facility failed to adjust the service plan for W1’s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of wandering and physical behaviors. On or about November 06, 2021, W1 emerged from the room of another resident and proceeded down the hall. W1 shoved Alleged Victim (AV) on the back, causing AV to stumble. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has history of resident-to-resident altercations, wandering and aggressive behaviors towards staff and residents. W1 Behavior/safety plan in place is to offer fruit, play music, staff monitoring W1’s interactions with others, and watch for other residents in close proximity to W1. On or about October 27, 2021, Camera review shows W1 walking up and down hallway and interacting with Alleged Victim. W1 grabbed AV shoulder and left forearm causing skin tear and bruising. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review, the facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents that include written policies and procedures on medical emergency response for all shifts. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, and promptly investigate all reports of abuse and suspected abuse. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/14/25 through 07/15/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 5 of 5 sampled residents (#'s 1, 2, 3, 4, and 5) Residents 1-5 service plans were not reflective of current residents needs which put R1 in immediate harm. This posed an immediate jeopardy situation which could threaten the health, safety, and welfare of the residents. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/14/25 through 07/15/25, the facility's failure to provide a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing was substantiated. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview and record review, conducted during a site visit on 07/14/25 through 07/15/25, the facility’s failure to have service plans reflective of and/or were not followed regarding the resident's prescribed altered diets was substantiated for 5 of 5 sampled residents (#'s 1,2, 3, 4, and 5) Resident's 1-5 had physician orders for altered diets and degrees of staff intervention while eating. The facility was not providing prescribed altered diets. This posed an immediate jeopardy situation and did pose an immediate threat to R1 and could threaten the health, safety, and welfare of other residents. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to immediately notify the local Department of any incident of abuse or suspected abuse. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

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.

Based on interview and record review, conducted during a site visit on 01/27/25, the facility’s failure to carry out medication and treatment orders as prescribed for sampled resident(s) was substantiated.

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.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 19, 2024, AV was pressing his/her pendant multiple times due to increased pain. Alleged Perpetrator 2 (AP2) responded to AV’s call saying, “I’m right “explicit” here, you don’t need to keep pressing your button”. Staff were able to overhear AP2 use profanity while responding to AV’s request for help. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from verbal abuse, which is a violation of Oregon Administrative Rules.

The facility failed to ensure facility may not require a resident to engage in an involuntary move out without first providing 30-day notice to the resident, resident's legal representative, and the resident's case manager. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 15, 2024, AV and Witness 1 (W1) were sitting at the dining table when W1 became agitated due to them being treated roughly by Alleged Perpetrator 2 (AP2) and when AV made a comment to W1, W1 hit AV. AP2 was behaving inappropriately in AP2’s care of W1. W1 became agitated from the rough treatment and when AV made a comment to W1, W1 turned to AV and hit AV. AP2 was over at the end of the dining area sitting by the window looking down at their cell phone when the incident occurred. AP2 failed to provide a safe environment, which is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 15, 2024, Witness 1 (W1) and Alleged Victim (AV) were sitting at the dining table when AV became agitated due to them being treated roughly by Alleged Perpetrator 2 (AP2) and when W1 made a comment to AV, AV hit W1. AP2 was behaving inappropriately in AP2’s care of AV. AV became agitated from the rough treatment and when W1 made a comment to AV, AV turned to W1 and hit W1. AP2 was over at the end of the dining area sitting by the window looking down at their cell phone when the incident occurred. AP2 failed to provide a safe environment, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to keep the interior of the facility free from unpleasant odors and keep clean all interior and exterior materials and surfaces, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week, which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to provide assistance with toileting and bowel and bladder management, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV was found on the floor by a staff in AV’s bedroom without any clothing on. When the staff went to find Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) on duty in the memory care unit, they were outside in the courtyard smoking. AP2 and AP3 had been found outside twice that night together. AP2 and AP3 had been told they could not leave the floor together as it is considered abandonment of a resident. AP2 and AP3 failed to provide a safe environment for AV, which is a neglect of care and constitutes abuse. The facility failed to assure AV received a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. Alleged Perpetrator 2 (AP2) bought a car from AV and did not pay the balance owed. AP2 was given two weeks to pay the balance, however, AP2 never paid the balance due. AP2 failed to protect AV from financial exploitation, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

The facility failed to assist residents with dressing and undressing, and toileting, which is a violation of Oregon Administrative Rules.

The facility failed to ensure only individuals with a diagnosis of dementia who are in need of support for the progressive symptoms of dementia for physical safety, or physical or cognitive function may reside in a memory care community, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is known to get up early and change and taken to the bathroom or have their brief changed. On or about October 16, 2022, AV was observed to have been upset and uncomfortable because their routine was broken. AV had been yelling from their bed for somebody to come help him/her get change and get up. The facility planned to have Alleged Perpetrator 3 (AP3) train and supervise Alleged Perpetrator 2 (AP2), who was not allowed to provide care to residents on their own. AP3 kept leaving AP2 unattended the day of the incident and passively failed to provide care to AV, which is neglect of care and constitutes abuse. The facility failed to assure service was provided to AV, which is a violation of Oregon Administrative Rules.

On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

The facility failed to provide three daily nutritious, palatable meals, which is a violation of Oregon Administrative Rules.

The facility failed to provide household services essential for the health and comfort of the resident, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week, which is a violation of Oregon Administrative Rules.

The facility failed to provide services to assist the resident in performing all activities of daily living, which is a violation of Oregon Administrator Rules.

On or about July 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from June 1, 2022 to June 30, 2022, for a total of 30 days.

The facility allegedly failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, platable meals in accordance with OAR 411-054-0030(1)(a) per complaint that the facility food is hard and unchewable.

he facility failed to ensure building is free of unpleasant odors in accordance with OAR 411-054-0200(4)(h), as stated in complaint that residents room smells like animal urine.

The facility failed to provide housekeeping services to the resident in accordance with OAR 411-054-0030(1)(g), as stated in complaint that resident room is not clean.

The allegation that the facility failed to provide a daily program of social and recreational activities in accordance with OAR 411-054-0030(1)(c) per complaint that there are no activities happening in the facility was verified.

The allegation that the facility failed to provide household services essential for the health and comfort of the resident that are based upon the resident's needs and preferences (e.g., floor cleaning, dusting, bed making, etc.) in accordance with OAR 411-054-0030(1)(e)(g) per complaint that the facility did not provide assistance with housekeeping, this task was being done by family members was verified.

Alleged Victim (AV) relies on the facility for h/h care. On or about October 15, 2021, Alleged Perpetrator (AP2) popped medications for Witness #1 (W1), then was distracted by another resident. AP2 then administered W1 medications to AV not realizing until after checking the computer. AP2 failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation or Oregon Administrative rules.