She moved into River Grove Memory Care in Lane County in October of 2016, needing a little more rehabilitation and care before she could go home with her husband. This 62-year-old woman had vascular dementia, but her diabetes was under control and she was able to walk more than 100 feet without stopping, a feat after spinal surgery in August 2013.

Her husband hoped that she would be out of the facility in 6 months with proper care.

Soon after Susan Bliven was admitted, the Oregon Department of Human Services forced the facility to restrict admissions. That means the facility was too far out of compliance with regulations to safely admit new residents, and the state had intervened to prevent new residents from coming in.

When last surveyed by DHS on Feb. 9, River Grove was out of compliance with more than a dozen Oregon Administrative Rules. The facility was understaffed, the staff was undertrained, and diet and hydration programs did not meet standards of frequency, nor did the facility meet sanitation standards.

Retirement homes are meant to be places where the elderly can live comfortably. But many facilities in Oregon are rife with abuse and neglect. Severe understaffing can set up caregivers for failure, and all it takes is one mistake to kill a member of this vulnerable community.

There is regulatory oversight on the state and local level, but legislation written in the 1970s and 1990s caps the civil penalties, or monetary fines, with which DHS can reprimand negligent and abusive facilities.

Ana Potter, DHS’s community based care manager, says, “for example, a fall resulting in a broken hip requiring hospitalization of a resident where the facility was substantiated for abuse may result in a fine as low as $300, with a cap of $500 for most cases of abuse, neglect or wrongdoing.”

The penalty structure for community based care facilities has not been substantially updated since 1977.

Unless they are restricted from admitting new residents, there is little incentive for facilities to change their policies in order to prevent neglect.

Demitria Haffenreffer, a consultant for River Grove who has worked in the field for 43 years, says, “I can just tell you on a national level that civil penalties don’t help. I don’t know what helps.” She adds, “Their only recourse, the state’s only recourse, is to restrict admissions.”

Haffenreffer’s consulting company, Haffenreffer & Associates Inc., helps facilities come into compliance with regulation.

The owner of River Grove is Terri Waldroff of Benicia, LLC, a company that owns several other retirement facilities in and out of state. She says that “when the state came in to do that survey, they admitted to the team that was here that they were going to get us. And that’s what they found, because they chose to.”

Waldroff adds that the families of residents at River Grove who have complained about conditions are uniquely unstable. “I’m talking about very dysfunctional families with mental health issues,” Waldroff says.

As for Susan Bliven, after she moved to River Grove her tests for hemoglobin A1c “went from a three-year average of 6.2 or 6.3, and after three months at River Grove it was 8.4,” according to her husband, Lee Bliven. The normal A1c range for those without diabetes is 4 to 5.9 percent, and anything over seven percent is concerning in diabetics. This jump signifies a sudden change from good to poor control of her glucose levels.

Her husband alleges that the jump came from poor food quality at River Grove.

Bliven fought for his wife’s well-being. He’s a large man with a long white beard and glasses, retired at 66. As a younger man he worked in four different states drilling water wells, but now in his free time he acts as a volunteer ombudsman at several other retirement facilities in Lane County, monitoring the care in the facility and making sure the residents are happy and healthy.

He kept close contact with the long-term care ombudsman at River Grove who gathers and reports complaints of poor care. Bliven continued reporting inadequate staffing and negligence to the ombudsman and Adult Protective Services (APS), and visited his wife almost daily to help take care of her.

“I changed her, I took her to the bathroom, I showered her a couple times because they didn’t have enough staff to shower her,” he says. “Anytime I was there I was her caregiver because there wasn’t enough staff.”

A new administrator, Samantha Borden, took over River Grove on Feb. 1. Lee kept up his complaints to the facility and his reports to APS regarding the state of the facility.

Soon after Borden took over River Grove, Lee Bliven received two letters from the facility claiming that his behavior was unacceptable. They alleged that he was making sexual comments to caregivers and that he frightened staff.

On April 3, Lee Bliven received a phone call from the administrators at River Grove that they were calling paramedics to take Susan to the hospital after she had fallen the previous night.

Bliven has power of attorney over his wife’s financial and medical decisions, so he has the right to refuse care on her behalf.

He rushed to the facility to try to stop EMTs from taking her, as he had scheduled a doctor appointment for later that afternoon.

Here the two accounts of the incident diverge somewhat. Borden claims Lee was behaving erratically, and she feared he might attack her. Lee says he was angry and claims they were trying to remove his wife from the property against his and her consent and were refusing to provide her care. What is clear, however, is that the police were called.

Borden claims that Bliven had locked himself inside with two caregivers, though Bliven says no one else was in the room while he provided care to his wife. The Eugene Police Department event reports for this incident do not mention any caregivers trapped in the room with him, though they do call the situation “a bit of a dispute over patient care.”

When Bliven left his wife’s room, he saw two police cars and three officers outside the facility.

Borden says, “Lee Bliven exited the building, he had his hands in the air saying ‘I’m leaving, I’m leaving, I’m leaving,’ the cops asked him to stop — he kept walking.”

The officers detained Bliven. “They grabbed my arms and held them behind my back,” he says. “They forced me down on the curb.”

Lee says he was held for 45 minutes before being released, and was told that he was banned from the facility where his wife lived. The EPD event report says Borden did not want Bliven “on the property any more and did not want him contacting the staff in any way, including by phone.”

The facility did not file charges and refused to provide an incident report regarding what happened on April 3.

Former staff at the facility say that the allegations of Lee’s inappropriate behaviors aren’t true. Erica Adams, who was fired in March after working for two years in various positions at River Grove, including lead caregiver, says she never heard from a single caregiver about inappropriate comments or behavior from Bliven.

“From my understanding, the management there thought that he was too nosy, and they didn’t want to deal with him,” Adams says.

Melanie Smith was a caregiver at River Grove until late April. “I feel personally that the reason I was fired was because I reported everything to management that I saw.”

Smith says the allegations of Bliven’s misconduct are “one hundred percent false. Lee came for Susan only and spoke to Susan only. I’ve spoken to him and I’ve seen his caregivers speak to him and he is totally appropriate.”

Smith says that, similar to her own situation, the new administrators wanted Lee Bliven gone because he reported to APS when he saw regulations broken or witnessed inappropriate behavior by staff.

When a loved one’s life is at stake, emotions can run high. Long-term care facilities, memory care units and residential care facilities hold the lives of this vulnerable population in their hands.

The Blivens are not the only family affected at River Grove by substandard care, and River Grove is not the only facility that fails to serve its residents and their families, according DHS data.

Dysfunctional Laws

Many facilities fail to protect elderly, vulnerable Oregonians. According to data retrieved from DHS current through July 2016, there have been 3,108 abuse complaints in Lane County since 2010. Of those, 36.2 percent were found to be substantiated in some way, either for abuse or rule violations.

Less than half of the substantiated cases saw any sort of fine assessed.

Adult Protective Services investigators say they are proud of their system and their ability to protect the elderly. Every complaint of abuse that fits APS criteria is investigated, according to the Lane County APS unit manager Becky Strickland.

Investigators spend an average of “10-12 hours per case, and then we have our outliers, the ones that might be 30 hours,” Strickland says. “Each worker is averaging two to three new investigations a day, and so you pencil that out with the average investigation being 10-12 hours and you can do your own math.”

Despite the heavy caseload, APS specialist Brent Wood says, “I enjoy what I do. I enjoy protecting people from harm. I think there’s a case to be made that this is the most vulnerable population in Lane County.”

Strickland says Lane County APS has a computer system in place that helps APS track perpetrators who move between facilities “and get them removed from employment.” Strickland notes the importance of good computer systems to support “the important work we do.”

APS sends the findings of its investigations to DHS, which then decides if the substantiated cases qualify as insances of abuse, rule violations or both. Rule violations often avoid fines until a pattern of failure is established, and the rules for civil penalties in Oregon tie the hands of DHS corrective action coordinators who levy fines against these facilities.

The amount of the civil penalty is based on “the severity of harm,” according to Ana Potter, DHS’s community based care manager. However, according to the Oregon Administrative Rules — a set of regulations based on Oregon law also known as the Oregon Revised Statutes — civil penalties for most cases of abuse or neglect are capped at $500.

“Given the fact that we are capped at $500 per occurrence, the way that they structured the fines is to have it ratchet up based on the level of harm,” Potter says. “We have an enhanced civil penalty, so if it resulted in certain types of abuse then we can fine higher.”

This enhanced civil penalty was instituted in 2010, and the rule reads: “The department shall impose a civil penalty of not less than $2,500 for each occurrence of substantiated abuse that resulted in the death, serious injury, rape, or sexual abuse of a resident. The civil penalty may not exceed $15,000 in any 90-day period.”

According to Eugene Weekly’s analysis of DHS data obtained last summer — data which DHS spokesperson Tom Peine admits has many inconsistencies — the average fine in Lane County from 2010 to July 2016 was $193, and the average lowers to $98.45 per substantiated case.

Across the state, only 122 fines were assessed at $2,500 or above from 2010 to the summer of 2016. Twenty-seven of those were for staffing shortages, and of those that remained, the minimum fine for enhanced civil penalties was issued 84 percent of the time.

APS data for the 2016-2017 financial year shows just over 50 percent of substantiated abuse cases in Lane County were classified as neglect from July 2016 to April 2017.

Common sense dictates that neglect is more likely in an understaffed facility.

But Oregon law does not specify a required ratio of caregivers to residents; it simply states, “Facilities must have qualified awake caregivers, sufficient in number, to meet the 24-hour scheduled and unscheduled needs of each resident.”

Many facilities fail to meet even this standard and face fines or restrictions from DHS for understaffing, according to EW’s analysis of DHS data.

These regulations were not decided upon by DHS or APS. According to Strickland, “My understanding is it’s set in stone because it was set in statute twenty years ago or whenever.”

Since setting caps on the fines, the Oregon Legislature has not changed the law other than adding enhanced penalties in 2010.

The current legislative session includes two bills that would affect these facilities, but they address fire safety standards and promote a new acuity tool to help facilities adequately understand their staffing needs. Neither bill addresses fines.

Facilities have no reason to increase their staffing to prevent neglect when the consequences for neglect are trivial. Tris Legacy was the administrator at River Grove before Samantha Borden, and he has 13 years of experience administering long-term facilities. He says civil penalties don’t affect facility policies in the slightest — they’re a drop in the bucket within their massive budgets.

Residents at River Grove pay $5,200 a month to receive care. If a facility is caught in the act of neglecting or abusing a resident, it may receive a fine of between $300 and $500.

If that facility hires a caregiver, then according to Legacy, “You’re going to be talking around $22,000 a year and that includes training time.” Legacy says staffing is one of the highest costs for running a facility. “Most of them are going to run the finest line they can with legal protocol.”

Legacy says that when facilities allow residents to get hurt, “90 percent of the time, it just entails neglect — and it’s not as if the caregivers are neglectful, it’s just they don’t have enough time, they don’t have enough staff, they don’t have enough training and support not to be neglectful.”

The facility in Lane County with the most substantiated cases is Brookdale Briarwood in Springfield. Since 2010 the facility has had 74 substantiated cases of rule-breaking or abuse, with an average fine of just $66.89. Without substantial fines as a motivator, there is no reason to fix the problem under current administrative rules.

Legacy adds that the systemic neglect is “industry wide. It’s not just this community; it’s not just Eugene. I believe it’s not even just Oregon.”

Legal Recourse Often Not an Option

With such low fines, some families turn to civil suits to seek justice for their loved ones. A lawsuit filed in November 2016 against Avamere Riverpark of Eugene (the third worst facility in Lane County for substantiated cases, according to DHS data from 2010-2016) paints a horrifying picture of abuse and neglect.

Maxine and Harvey Hanson moved into Avamere Riverpark on March 14, 2014. Within a year, both were dead.

The lawsuit, filed by Dyann Wilson, the personal representative of their estates, alleges that between March 14, 2014 and November 24, 2014, Harvey Hanson “sustained a minimum of 13 falls, including head trauma, a nearly severed ear requiring sutures, numerous skin tears and lacerations, and multiple bruises with pain and swelling.”

The facility, the lawsuit alleges, failed to change his care plan to prevent these falls.

Avamere Riverpark placed Hanson on hospice care with Northwest Hospice (a company also owned by Avamere) with the promise that the facility would begin providing rehab that, the suit alleges, it did not provide. After being hospitalized briefly on Nov. 24 when a fall led to a serious cut on his hand, Harvey Hanson returned to the facility “conscious and alert.”

On Nov. 27, the suit alleges that Riverpark “began medicating Mr. Hanson with doses of narcotics and tranquilizers that effectively restrained him in his bed” and prevented him from eating and drinking.  As a result, “Mr. Hanson suffered painful and distressing multisystem failure, starvation and dehydration.”

Harvey Hanson died on Dec. 7, 2014.

His wife outlived him, but not by much.

Maxine Hanson faced grotesque indignities as a result of neglect: “Defendants consistently ignored Mrs. Hanson’s oral care, resulting in dental disease and decay, including the growth of a colony of fruit flies inside her oral cavity.”

According to the $2.6 million lawsuit, Maxine Hanson, like her husband, was placed on hospice despite no change to her condition. The incident that led to her death was painfully simple. The footrests on her wheelchair were removed at some earlier date, so that her feet dragged painfully on the floor.

On Jan. 20, “As the aide was pushing Mrs. Hanson in the wheelchair into her bathroom, Mrs. Hanson’s feet caught on the floor and she fell forward striking her head on the door jam and floor, causing severe skull and facial fractures, lacerations, and brain bleed.”

Maxine Hanson died Jan. 24, 2015.

The attorney for the case, Tom Petersen, says the lawsuit is pending. “The defendants have answered the complaint,” he says, and “we are currently undertaking discovery.”

Petersen says the case has a trial date set for early next year.

Asked for comment on the lawsuit, Avamere Riverpark’s representative Deborah Nedelcove provided a letter. “These lawsuits siphon needed resources away from resident care and result in providing money to family members, not the residents themselves in most cases. The truth about resident care is often buried by the claims made by these lawsuits.”

Avamere is a large company that controls 12 memory care facilities, 27 hospice communities, eight rehab facilities, 11 assisted living facilities and 32 nursing facilities across four different states. The founder and chairman of the board, Karl R. Miller Jr., owns an $11.3-million mansion on an island in Lake Oswego, according to The Oregonian.

Despite concerns from Avamere representatives that there are too many lawsuits, many abused residents do not take the facilities to court. This, according to attorney Emilia Gardner at Arnold Law Firm, is because the suits are “complex, they’re extremely expensive, and if they’re so good that they’ll certainly win, they get settled in advance.”

Victims of abuse often die before they can file lawsuits, or they are dementia patients who may not remember details of their abuse, according to attorneys who deal with such cases.

With such complicated laws and such inconsistent witnesses, the cases are often too difficult to win to ever see court.

A Brighter Future

Lee Bliven was unable to care for his wife after he was banned from River Grove, but he still kept in contact with her. She spent almost two weeks at River Grove without another medical incident, but on April 15 she became very ill with clostridium difficile colitis, a recurring bacterial infection.

Kellie Mick, whose mother Judi Wheeler lives in the facility, says she witnessed Susan Bliven in need of a transfer that did not occur for the hour and a half Mick was at the facility that day.

Susan became ill and vomited on herself, and Mick says she helped the sole caregiver in the building clean her up. According to administrator Samantha Borden, the facility was fully staffed that night, but Mick says the sole caregiver was left alone there with malfunctioning communications systems.

Administrator Borden says the River Grove was fully staffed that day, and there were no filed complaints of a resident waiting to be toileted.

Lee Bliven was not permitted to visit or help his wife at that time. Mick says, “There is no way in God’s green Earth that he shouldn’t have known what was going on with his wife, been able to come there and comfort her and clean her up.”

Mick adds, “Not only are they not up to snuff, but they blocked him so he can’t even catch what they don’t do. They’re not good enough to not have family members.”

The next day, paramedics took Susan Bliven to the hospital. Her husband was notified by text message.

“It makes me sad,” Lee Bliven says. “I tried and tried. You want to help the facility, but they won’t let you. And when she was sick and getting ready to go to the hospital, the facility never even called me to tell me about that.”

But the trip to the hospital was a blessing in disguise. When Susan arrived at the hospital, Lee says, “the doctor saw something in Susan.” The doctor thought Susan could get significantly better if the hospital took an interest.

After a number of consultations, Susan Bliven was put on an intense regiment of physical therapy with Oregon Rehabilitation Center at the Sacred Heart Medical Center near the University of Oregon. Lee says she gets at least three hours of physical therapy each day.

“Right now, and she’s still progressing, she is as good as she was when we originally came out of rehab in January of 2014,” Bliven says.

“I’ve got my wife back. I’ve got my Susan back. It’s a miracle.”

When asked how it felt to witness this change in his wife, to see her improve after a long path downhill over the past 6 months at River Grove, Lee Bliven says, “If Susan got care like this she would have been home with me a long time ago. And that’s what kills me — that we put her through so much and to go to a place that’s supposed to help …” he pauses, his voice breaking with emotion.

“They tried to kill her. That’s the only thing I can say. Lack of care, lack of food, lack of basic respect. There’s nothing you can do.”

Lee wiped tears from his eyes. On May 3, Susan moved back into his home from the hospital. He says he’s still not permitted on the premises at River Grove, so one of his children will have to pick up her possessions.

Other residents, including Kellie Mick’s mother, Judi Wheeler, remain at the facility.

Mick says Wheeler was left for several days at River Grove without medication for her glaucoma, leading to a 12-point increase in pressure in her eye, a concerning shift that Mick says could lead to blindness. This mistake is also documented in the Feb. 9 survey of the facility.

“I no longer have a relationship with the administration, and that is not healthy,” Mick says. She says she hopes the ownership of the facility will change, and that protocol there will change with it. “No other person should go through this.”

“I watch my mom deteriorate and be stressed all the time, so that the little time she has left, she spends miserable,” Mick says. “How is that ok? And how do you pay someone to do that to your loved one?”

The administrators at River Grove say they are hoping to be surveyed again in May, and they say they should be in compliance by then.

The majority of long-term care facilities are businesses. The goal of corporate ownership for these businesses is profit, and the most expensive cost of doing business is properly staffing facilities.

Ex-administrator Tris Legacy says he felt trapped at River Grove and other facilities. “It’s very frustrating. You’re in that vise between what is corporate and what is community.”

DHS fines for abuse, which are determined by the Legislature, achieve nothing, Legacy reiterates: “If you’re going to fine me $300 for not caring for this person but in the month they were there they paid me $5,000, so what?”

It’s left to legislators to answer the question. Rep. Julie Fahey says she’s supportive of increasing the fines. She says she wants “the fine to be high enough to hold people accountable and actually change behavior when abuse happens.” Fahey adds that transparency is important, so families can know which facilities have had substantiated abuse cases.

“It’s important that the penalty matches the severity of the wrongdoing,” Fahey says.

This story was done with data reporting by Kenny Jacoby. The DHS data was originally obtained with the investigative reporting project at the University of Oregon School of Journalism and Communication.