Inspection Reports for Aspen Ridge Retirement Community
1010 NE Purcell Blvd, Bend, OR 97701, United States, OR
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Inspection Report
Complaint Investigation
Census: 51
Capacity: 95
Deficiencies: 22
Sep 3, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, Aspen Ridge Retirement Community exhibited numerous deficiencies including failure to maintain accurate resident records, inadequate investigation and reporting of abuse, incomplete resident evaluations and service plans, insufficient infection prevention protocols, incomplete RN assessments for significant changes of condition, failure to submit required staffing tool approvals, and inadequate staff training and documentation.
Complaint Details
Survey YRZR dated 2024-08-20 was a Complaint Investigation related to licensure complaints with 3 deficiencies noted.
Deficiencies (22)
| Description |
|---|
| C0155 - Facility Administration: Records: Failed to maintain complete and accurate resident records for 5 sampled residents |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report suspected abuse or injury of unknown cause for 2 sampled residents |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to perform quarterly resident evaluations for 4 sampled residents |
| C0260 - Service Plan: General: Failed to update service plans quarterly, ensure accessibility, and provide clear direction for 3 sampled residents |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor interventions for changes of condition for 4 sampled residents |
| C0280 - Resident Health Services: Failed to ensure RN completed assessments for significant changes of condition for 2 sampled residents |
| C0282 - RN Delegation and Teaching: Failed to provide and document RN delegation and teaching for 1 sampled resident receiving injections |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate and review outside provider services for 3 sampled residents |
| C0295 - Infection Prevention & Control: Failed to maintain effective infection prevention protocols during meal service |
| C0301 - Systems: Medication Administration: Failed to ensure medications were set-up, administered, and documented properly |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when residents refused medications for 2 sampled residents |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to submit proprietary ABST approval form by deadline |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and elements for 1 sampled resident |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update ABST evaluations quarterly for multiple residents |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure pre-service orientation and dementia training for 4 newly hired staff |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure 2 caregiving staff demonstrated competency and completed First Aid and abdominal thrust training within 30 days |
| C0374 - Annual and Biennial Inservice for All Staff: Failed to document required annual in-service training and designate LGBTQIA2S+ training representatives |
| C0420 - Fire and Life Safety: Safety: Failed to document all required fire drill components and provide fire safety instruction on alternate months |
| C0422 - Fire and Life Safety: Training for Residents: Failed to provide and document annual fire safety training for residents |
| C0455 - Inspections and Investigation: Insp Interval: Failed to implement and satisfy relicensure survey plan of correction |
| C0612 - General Building: Floors: Failed to maintain carpeting to minimize resistance and prevent tripping hazards |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to honor resident food choices and maintain kitchen sanitation |
Report Facts
Inspections on page: 5
Total deficiencies: 32
Total surveys: 5
Licensing violations: 20
Notices: 1
Licensed beds: 95
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Regional VP of Operations/Interim Executive Director | Named in multiple findings and acknowledged deficiencies during interviews |
| Staff 2 | Resident Care Coordinator (RCC) | Named in multiple findings and acknowledged deficiencies during interviews |
| Witness 1 | RN Consultant | Named in multiple findings and acknowledged deficiencies during interviews |
| Staff 5 | Delegation RN | Acknowledged missing delegation documentation in nursing records |
| Staff 3 | Environmental Services Assistant | Acknowledged facility environmental issues and fire safety findings |
| Staff 4 | Director of Environmental Services | Acknowledged fire safety and resident training deficiencies |
| Staff 11 | Caregiver | Named in medication refusal and training deficiencies |
| Staff 16 | Medication Technician | Named in training and competency deficiencies |
| Staff 19 | Caregiver | Named in training and competency deficiencies |
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