Print Violation: 00407790-AP-358823

Provider Information

Shore Pines Senior Living

93975 OCEAN WAY
Gold Beach, OR 97444

Date: 6/12/2025
Report number: 00407790-AP-358823
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a therapeutic diet
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025 (1)(a) and (b)
External site: 411-054-0027 (1)(g) and (s)
External site: 411-054-0028 (2)
External site: 411-054-0036 (2)(g)
External site: 411-054-0055 (1)(a) and (f)
Findings: The Alleged Victim (AV) relies on the facility to manage their physician ordered specialized therapeutic diet. The AV had care plan interventions for meals, including but not limited to, monitoring, cueing, reminders to chew thoroughly, and encourage water if appears to be struggling to chew or swallow. According to an investigation, on or about June 12, 2025, the AV was served a dry Philly Melt sandwich for the evening meal. The AV was not monitored while eating. The AV choked on the sandwich, became unresponsive, and was taken to the hospital by EMS. The facility failed to follow the AV’s therapeutic diet order and failed to follow the AV's care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.
Sanction: ALFCP25-00401 $1500.00 fine assessed