Dangerously low staffing may have contributed to the death of a woman in a Bend memory care facility last month, and state licensing officials have since barred the facility from admitting any new residents.

The resident of Aspen Ridge Memory Care was left outside in 97-degree heat for as much as two hours while wearing heavy winter fleece, pants, and a long-sleeved sweater, according to a Department of Human Services report. When emergency personnel found the woman, her skin was hot to the touch and her body temperature was 105 degrees, according to the report. She later died at a hospital of hyperthermia.

At the time of the Aug. 30 incident, there was one medical technician on duty caring for about 40 residents, said Fred Steele, Oregon Longterm Care Ombudsman. Two caregivers had called in sick, and a decision was made not to call in additional staffers, Steele said.

An Oregon Department of Human Services investigation led to the agency issuing licensing conditions that bar Aspen Ridge from taking new residents. Information about the conditions and the current violations are not publicly available, despite being required to be, because of a computer glitch, Steele said.

Neither Aspen Ridge Memory Care nor the Department of Human Services responded to numerous calls and emails seeking information. Aspen Ridge has been operated by Frontier Senior Living, a Dallas-based chain that manages senior living facilities nationwide, since August 2023. A Georgia real estate investment company is listed on Oregon business registration licenses as a contact for Aspen Ridge, but did not provide any information.

Based upon documentation provided by the ombudsman’s office, the death of the resident “constitutes a threat to the health, safety and welfare” of the residents at Aspen Ridge, according to the Oregon Department of Human Services report provided by the ombudsman’s office.

“All residents at the facility are at risk for serious harm and immediate jeopardy,” according to the investigation report dated Sept. 3.

Stephen Gunnels, Deschutes County district attorney, said his office had not receive any reports of the woman’s unattended death being a criminal matter.

When the human services investigators returned to Aspen Ridge on Sept. 18, four additional violations of state laws were found. The facility is now required to provide proof that new hires are trained within 30 days of hiring, to provide more staff for each shift, to establish a checklist for routinely watching residents entering and exiting the locked courtyard every 30 minutes and ensure that all exit doors, especially the courtyard doors, have alarms installed.

Starting Sept. 20, the facility was required to submit written reports every two weeks to the Department of Human Services addressing the areas of concern, particularly staffing levels and courtyard safety checks. Notices restricting admissions are posted on the doors of the facility, to give it time to address the violations, according to the report.

“We are still investigating,” Steele said. “Our charge is to effectively represent those who receive care in long-term care settings. There should never be a death like this in a state licensed facility.

“We take these things very seriously. No family should have to experience that a loved one dies in such a way at a state licensed facility.”

The death at Aspen Ridge is similar to a December death at Mt. Hood Senior Living in Sandy, where a woman, who had just been moved to the facility, wandered outside and died. Steele said the Mt. Hood incident and the Aspen Ridge incident are similar and should never have occurred.

This is not the first time Aspen Ridge has been under scrutiny by the Department of Human Services. In 2019, it was cited for failing to protect a resident from rough treatment. And in 2018, there were four incidents of resident altercations and a $375 fine was assessed due to failing to provide safe environments.

From October 2016 to January 2018, Aspen Ridge was not in compliance with Oregon rules for residential care facilities and the noncompliance placed residents at harm or risk for harm, according to the department.