Inspection Reports for Aspen Ridge Memory Care
1025 NE Purcell Blvd, Bend, OR 97701, United States, OR, 97701
Back to Facility ProfileDeficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 32
Jun 4, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failure to report and investigate resident altercations and injuries, inadequate staffing and training, incomplete service plans, infection control lapses, and failure to maintain safe and sanitary conditions. Several deficiencies were repeated and plans of correction were documented but not always fully implemented.
Complaint Details
The facility failed to immediately report resident to resident physical altercations and injuries of unknown cause to the local SPD office across multiple inspections. Several incidents involving residents #3, #5, #6, #7, #9, #10, and #12 were not reported timely or investigated properly. Staff acknowledged these failures during interviews and corrective actions were requested.
Deficiencies (32)
| Description |
|---|
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for sampled residents. |
| Z0163 - Nutrition and Hydration: Deficiency noted related to nutrition and hydration. |
| C0155 - Facility Administration: Records: Failed to develop and implement a written policy prohibiting falsification of records. |
| C0260 - Service Plan: General: Failed to update service plans quarterly and ensure plans reflected current resident needs. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient direct care staff to meet resident needs. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and accurately use acuity-based staffing tool. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately report resident altercations and injuries to local SPD office and investigate injuries of unknown cause. |
| C0242 - Resident Services: Activities: Failed to provide an activity program based on resident interests and needs. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by appropriate service planning team. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor residents with significant changes in condition. |
| C0280 - Resident Health Services: Failed to complete RN assessments for significant changes in condition. |
| C0295 - Infection Prevention & Control: Failed to maintain effective infection prevention and control protocols. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused consent to orders. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included necessary instructions. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychoactive medications were given only after non-drug interventions. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff had required training within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety training at least every other month. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure doors exiting to courtyards were equipped with alarms or acceptable alert systems. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required training, orientation, and competency within required timeframes. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0176 - Resident Rooms: Failed to ensure residents were not locked outside their rooms and rooms were individually identified. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and food storage in accordance with Food Sanitation Rules. |
| C0231 - Reporting & Investigating Abuse-Other Action (2021): Failed to immediately report suspected abuse and investigate injuries of unknown cause. |
| C0270 - Change of Condition and Monitoring (2021): Failed to document monitoring of residents consistent with evaluated needs for falls. |
| C0280 - Resident Health Services (2021): Failed to conduct significant change of condition assessment for severe weight loss. |
| C0305 - Systems: Resident Right to Refuse (2021): Failed to notify physician/practitioner when resident refused consent to orders. |
| C0372 - Training Within 30 Days: Direct Care Staff (2021): Failed to ensure newly hired direct care staff had required training within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety (2021): Failed to provide fire and life safety training and include required components on fire drill records. |
| C0540 - Heating and Ventilation: Failed to ensure heating elements did not exceed safe temperature limits. |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure outdoor furniture was sufficient weight and design to prevent elopement. |
Report Facts
Inspections on page: 6
Total deficiencies: 43
Total surveys: 6
Total notices: 3
Licensed beds: 43
Facility census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Regional Vice President/Interim Administrator | Named in multiple findings related to administration, reporting failures, and acknowledged findings during interviews |
| Staff 2 | RN / Health Services Director | Named in findings related to reporting, assessments, and acknowledged findings during interviews |
| Staff 15 | Executive Director | Named in findings related to reporting failures and staff training |
| Staff 26 | Health Services Director / RN | Named in findings related to reporting, infection control, and acknowledged findings |
| Staff 28 | Executive Director | Named in findings related to reporting, infection control, and acknowledged findings |
| Staff 38 | Caregiver / Medication Technician | Named in infection prevention deficiency and medication competency |
| Staff 41 | Caregiver | Named in infection prevention deficiency |
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