The Aspen Ridge Memory Care building is seen on Thursday in Bend.  

The Bend memory care facility where a woman died of hyperthermia after being left in the sun this summer had been cited for 14 instances of abuse or neglect by Adult Protective Services over the past seven years, according to public records.

Some abuse citations carried a nominal fine. Others don’t have a fine attached, but a corrective action in place.

Aspen Ridge Memory Care, where the woman died Aug. 30, is not allowed to accept any new residents until the Department of Human Services, which oversees the Adult Protective Services division, deems it safe.

Police are investigating the death of the woman, whose name and age were not released. The Bulletin received numerous phone calls from families and residents concerned about conditions at the facility on Purcell Boulevard. Few wanted to speak up about the conditions for fear of retaliation.

More Coverage

Woman’s death at Bend memory care facility raises alarms

But more than that, the death has thrown the entire Aspen Ridge community into chaos.

Su Skjersaa, a resident of the Aspen Ridge assisted living facility across the street from the memory care unit, said the place feels chaotic. Staff have changed. A temporary group of caregivers have been hired. Management staff have from one unit have been moved to another.

For weeks, Skjersaa said, the residents have been eating off of paper plates and using plastic cutlery because the dishwasher is broken.

“It was better when I first moved here about six months ago,” Skjersaa said. “I have a beautiful apartment, but I’m pretty sure if I needed anything at night, no one would come.

“A lot of people here feel the turmoil.”

Company responds

The managing company for Aspen Ridge acknowledged that it is still conducting its own internal investigation into the woman’s death, said Leah Miller, Frontier Senior Living vice president of sales and marketing, which took over management of Aspen Ridge in 2023.

“We’re committed to providing a safe environment for our residents,” Miller said. “We’re dealing with the local authorities and the Department of Human Services.”

Public reporting on the inspections and the findings of those inspections, as well as results of investigations for abuse, can be found on the Department of Human Services website.

Generally they’re posted quickly, but a snafu with the department’s content management system since mid-August is requiring new reports to be uploaded manually.

In Oregon there’s a long-term care ombudsman who’s job it is to investigate and support the quality of life for those living in long-term care facilities.

“The Long-Term Care Ombudsman program is concerned that prospective residents and families are currently not able to make informed decisions about Oregon’s long term care facilities due to the lack of updating occurring with the Oregon Department of Human Services facilities search website,” said Fred Steele, Long-Term Care Ombudsman. “Any information related to inspections and violations that should have been uploaded into the public accessible system has not been made current since early September.”

Looking into the past

The Bend woman’s death is the second death investigated at a long-term care facility in Oregon in eight months. The first occurred on Christmas Day at Mt. Hood Senior Living when a woman who had just moved to a state-licensed memory care facility got lost and died after spending the night outside.

The Oregon Department of Human Services imposed a condition on the license when there’s a serious incident involved, said Elisa Williams, the department’s communications manager. When a serious incident is reported, the department works with the facility immediately while the due diligence plays out, Williams said. If the death of a resident is suspected because of a licensing violation, neglect or abuse, the facility can be sanctioned for substantiated abuse or neglect that potentially could result in a death, she said.

Public documents paint a picture of substantiated instances of abuse or neglect at Aspen Ridge Memory Care.

In March, the department determined that the facility failed to ensure residents’ physical altercations were reported. In one instance a resident in the memory care unit took other residents’ food and beverages and was intrusive, and the incident ended with yelling and a resident slapping another resident. A follow up visit in July showed a plan for correction involved a charting system that requires the team to note when incidents occur and for the resident care coordinator, health services director and executive director to review these reports during weekly meetings.

Also in March during a visit, the department determined the memory care facility lacked scheduled and unscheduled activities for residents. During the visit, residents were observed seated, unengaged in hallways and common areas, wandering the halls and sitting in front of the TV. Since that visit, Aspen Ridge hired a lifestyles director to ensure proper engagement, according to the public records.

A 2019 incident of physical abuse shows that minor harm from rough treatment was determined. “The facility failed to protect the alleged victim No. 1 from rough treatment (from another resident),” according to the records. No fine was levied.

In 2018 there were four instances of neglect on file. One involved two residents and the facility “failed to implement interventions and appropriate care plan related to behaviors,” according to documents. That was a violation of residents’ rights and was considered neglect of care and constituted abuse, according to the records. A $375 fine was assessed.

In another incident, the facility failed to place fall mats in the resident’s room, despite the resident being a fall risk, according to public documents. The resident was hospitalized because of a fall that led to a brain bleed and a hip fracture. The facility was fined $1,500 for failing to provide a safe environment.

Editor’s note: This article has been corrected. The original version misspelled Su Skjersaa’s name and mischaracterized repair work as undone. The Bulletin regrets the error.