Desert Sage Memory Care

Last inspection

November 7, 2024

Inspections

5, 22 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

11

Regulatory actions

2

Fines assessed

$20,250.00 (7 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• July 17, 2025 to October 6, 2025: License Condition, Failed to provide safe environment RCFCD25-00776; incident: CALMS - 00083527
  The following statement of violations stem from preliminary evidence and interviews collected from Adult Protective Services (APS) Investigation #00413708 opened on July 15, 2025.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
• September 13, 2024 to June 11, 2025: License Condition, Failed to provide safe environment RCFCD24-00925; incident: CALMS - 00060527
  ODHS concludes that Respondents acts or omissions create a situation that necessitates ODHS to issue a license condition. That is because the incidents outlined above places all residents at risk for immediate jeopardy.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0070 (Staffing Requirements and Training)

Inspections

• November 7, 2024: Complaint Investig., 2 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated
• August 20, 2024: Complaint Investig., 4 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• March 6, 2024: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected June 4, 2025
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected May 7, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected May 7, 2024
  Show all 22

  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected June 4, 2025
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected May 7, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected June 4, 2025
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected June 4, 2025
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 16, 2024
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected December 16, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 7, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected June 4, 2025
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected December 16, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected June 4, 2025
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected June 4, 2025
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected June 4, 2025
  • Z0176: Resident Rooms severity level 2, scope L2 Pattern, corrected December 16, 2024
• May 18, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• July 19, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 17, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 17, 2022

Substantiated abuse or neglect

• July 14, 2025: Failed to provide safe environment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  On or about July 14, 2025, the Alleged Victim (AV) suffered an unwitnessed fall in the facility's North courtyard. At time of incident, AV was found lying on the ground between 3:00PM and 3:20PM and outside temperatures were between 85 and 93 degrees. Based on facility documentation and interviews, AV's placement in memory care is due to AV's significant cognitive deficits and mobility issues which require constant supervision and support. These deficits make AV vulnerable to extreme heat due AV not being able to understand the risks associated with his/her surroundings. AV was last seen in his/her room between 2:20PM and 2:30PM. Although the times provided by witnesses regarding the last time AV was physically seen are approximated, an investigation determined the likely amount of time that AV was on the ground range from 30 minutes to almost an hour. The timeline may be within AV's 1-hour safety check protocol; however, AV was outside long enough to have been negatively affected by the heat. AV complained of pain and heat related discomfort and was taken to the hospital and treated for Heat Illness. The combination of heat and inadequate supervision by facility staff, significantly increased AV's risk of heat-related illness. The facility failed to provide the basic care or services necessary to maintain the health and safety of AV, resulting in AV suffering from Heat Illness, placing AV at risk of serious harm due to AV's fall history requiring frequent safety checks. The facility's failure is a serious violation of resident rights, is considered neglect of care which constitutes abuse. Additional corrective action was taken concerning this case. ODHS issued condition, RCFCD25-00776, effective July 17, 2025.

• May 24, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On December 4, 2025, ODHS Adult Protective Services (APS) completed investigation #00403592 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) and Witness 1 (W1) both live at Respondent’s facility. On May 24, 2025, the facility failed to adequately monitor AV despite his/her known behaviors and recent increase in resident-to-resident altercations. During the May 24 incident, AV attempted to take W1’s food and entered W1’s personal space, which triggered W1 to strike AV. Prior to this event, the facility was aware of escalating behaviors and had a responsibility to implement sufficient interventions and monitoring to mitigate these risks. The failure to do so resulted in unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• April 8, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about April 8, 2025, Alleged Victim (AV) suffered a fall while left unattended in the common area of the facility. Shortly before incident, two caregivers assisted AV from his/her bed to his/her wheelchair because it was lunchtime, leaving AV unattended in the common area to assist other residents to the dining room for lunch. Based on facility documentation and interviews. The caregivers that assisted AV forgot to place the foot pegs on AV's wheelchair as directed by AV's fall prevention plan. AV is bed bound and only gets up for mealtimes. AV is a two person assist with transfers, is on hospice, is at end of life receiving only comfort measures, and is non-verbal. The facility had caregivers involved in incident repeat their training on how to read a service plan to prevent falls. The investigation determined the facility failed to follow AV's fall prevention plan as stated in AV's care plan and failed to ensure staff were well trained on AV's fall prevention plan, which resulted in risk of serious harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 30, 2024: Failed to provide safe environment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $15,000.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  On or about August 30, 2024, at approximately 11:50am, Alleged Victim (AV) was found unresponsive by facility staff in the outdoor courtyard of the facility. EMS was contacted and AV was transported to the hospital for treatment. Based on facility documentation and interviews, AV was dressed in warm clothing, including two sweaters, one described as a heavy winter fleece, and long pants. Per the U.S. Government's National Oceanic and Atmospheric Administration, the temperature the day of the incident rose from 72 degrees Fahrenheit at 8:55AM to 90 degrees Fahrenheit at 11:55AM, five minutes after AV was reportedly discovered. EMS reported that AV's temperature was 109 degrees Fahrenheit and AV's temperature upon arrival at the hospital was documented as 103.6 degrees Fahrenheit after ice packs had been used to decrease AV's body temperature. AV required resuscitation and intubation to protect AV's airways while in the Emergency Department. AV was admitted to the hospital's Intensive Care Unit, where AV ultimately passed away on September 1, 2024. The county Medical Examiner determined AV's cause of death was multi-system organ failure due to hyperthermia with contributing factors of AV having dementia and being left outside in extreme heat. At time of incident, facility records show only one care staff was working the day shift on August 30, 2024. The facility's posted staffing plan indicated there are to be 3 caregivers and 2 med techs working dayshift. The staff schedule for the day only had 2 caregivers and 1 med tech which did not meet the posted staffing. The two scheduled caregivers for the day called out sick and no additional facility staff or agency staff were called in. At time of incident, there was a total of 33 residents present at the facility during the dayshift on August 30, 2024. Facility did not have a written policy in place regarding safety checks of residents in the courtyard areas of the facility. Additionally, there was significant inconsistencies in witnesses report of the facility's practice of safety checks of the courtyards, or even the existence of a policy, suggesting that the expectations were clear to staff. The facility failed to provide adequate staffing to ensure the safety and supervision of the resident which resulted in AV sitting outside for an unknown amount of time in clothing inappropriate for the weather conditions at time of incident. The facility's failure The facility's failure to provide a safe environment, have effective oversight of residents, and ensure there were enough properly trained staff available to have oversight of all residents resulted in AV suffering a heat stroke/hyperthermia that resulted in AV's death which is a serious violation of resident rights, is considered serious neglect of care, which constitutes abuse. ODHS found this incident to be a risk of Immediate Jeopardy at time of initial intake, in which ODHS issued Immediate Jeopardy Condition, RCFCD24-00925, on September 13, 2024, prior to completion of APS Investigation, #0035180, because the facility’s failure to comply with Oregon Administrative Rules likely resulted in death of AV which was confirmed on July 1, 2025, at time APS Investigation, #0035180 was completed.

• August 10, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 10, 2024, the Alleged Victim (AV) suffered a fall and was found on the floor in the activity room by staff. AV was transported to the hospital and had suffered a goose egg to his/her head and bruising on his/her face, elbow and hip area. AV suffered three more falls, with one requiring transportation to the hospital. AV's care plan was not updated to include interventions to ensure AV's safety from falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 11, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about May 7, 2024, the Alleged Victim (AV) moved from the assisted living to the memory care side of the facility. On or about May 11, 2024 AV was found sitting on a bench complaining of pain in his/her knee and on May 12, 2024, AV was unable to bear weight on his/her left leg and was sent out to the hospital and diagnosed with a fractured hip. During AV's transfer from assisted living to memory care, AV's medication for cognition enhancement was not transferred, and the missing medication was not discovered until May 16, 2024, upon AV's return from the hospital. Once AV returned from the hospital, AV experienced recurring falls, mostly from trying to transfer from his/her wheelchair to the bed. On or about May 20, 2024, AV began taking his/her cognition medication again, AV's cognition has drastically improved, resulting in a decrease of falls. The facility's failure to provide a safe medication administration system resulted in AV suffering a fall which resulted in a fractured hip. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 9, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk. On or about May 9, 2024, AV was found on the floor crawling out of AV's apartment. AV had injuries to his/her cheek along with neck and chest pain. AV was sent out to the hospital for evaluation. The facility failed to ensure interventions were in place to reduce AV's risk of falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 6, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV), a resident under the facility’s care, was given another resident’s medications by Alleged Perpetrator 2 (AP2) on or about February 6, 2026. Shortly after receiving the incorrect medication, AV became unresponsive and experienced bradycardia, requiring transport to the hospital for treatment. Facility documentation and interviews show that AP2 was properly trained and had met competency requirements for medication administration prior to this incident involving AV. AP2’s medication error caused AV unreasonable discomfort and adverse side effects, is considered neglect of care and constitutes abuse. The facility failed to maintain a safe medication administration system to ensure AV received medications as ordered which is a violation of Oregon Administrative Rules.

• December 10, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about December 10, 2025, Alleged Perpetrator 2 (AP2) threatened Alleged Victim (AV) with a “time out” and pushed AV’s wheelchair against a wall so forcefully that AV’s knees were touching the wall. When AV attempted to stand, AP2 restrained AV by pressing down on AV’s shoulders, preventing AV from standing. AV is a resident in memory care with a diagnosis of a memory-related disease and requires staff assistance for behavior management, orientation, and redirection. Facility documentation and interviews confirm AP2 had completed required trainings on dementia care, wandering/elopement, and resident rights. At the time of the incident, AP2 was described as short-tempered and was observed applying physical restraint to AV. AP2's actions constitute wrongful restraint, which is considered abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• July 14, 2025: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/21/25, the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare or residents was substantiated for 1 of 1 sampled resident (#1). This posed an immediate harm situation, which put the health and safety of residents at risk. Findings include but are not limited to: A review of facility meeting notes dated 07/17/25 with participants listed regarding the incident on 07/14/25 including an attachment undated showing the facility policy to be locking the courtyard doors when outside temperatures reached 95 degrees. A review of the ER After Visit Summary dated 07/14/25 indicated the following: - Resident temperature 97.9 F - Reason for visit: Fall - Diagnosis: Heat collapse A review of the policy for securing courtyard doors as of 07/17/25 following condition being placed on the building indicated the following: - Excessive heat (temperatures above 85 degrees) - Heavy rain - Excessive winds - Poor air quality - Excessive freezing temperatures - Hail, Ice, Snow - Weather advisories - National Weather Service - Police issued shelter in place A review of the Safety plan for the courtyards as of 07/17/25 following condition being placed on the building indicated the following: - Sign off sheets for courtyard checks - Documentation hourly for courtyard doors locked - Assigned caregivers at specific courtyards - Documentation of all resident safety checks A review of Resident 1’s progress notes dated 07/01/25 through 07/21/25 indicated the following: - Residents initial fall outside 07/14/25; - Residents return from hospital post fall with heat illness dated 07/14/25; - Safety checks placed 07/15/25; - Push hydrating fluids as tolerated; - On 07/16/25, the resident had another fall and sent to hospital; - On 07/18/25 the resident had chest pain was sent out to the hospital; and - On 07/19/25 the resident had another fall and was sent to hospital. During an interview with Staff 1 stated they were no longer documenting safety checks after June 9th, 2025, when the previous condition had been lifted. Staff 1 confirmed the facility had made adequate efforts to support and remedy the violations that were placed by The State on 07/17/25 and stated that the courtyard door policy was currently under review by the president and vice president of the company. The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents during extreme heat. This resulted in the resident being hospitalized. The findings of the investigation were reviewed and acknowledged by Staff 1. The facility’s failure to exercise reasonable precautions is a violation of Oregon Administrative Rules.

• August 15, 2024: Failed to provide appropriate staffing Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Facility failure to have sufficient care giving staff to meet the 24 hour scheduled and unscheduled needs of residents per complaint of service plans not being updated and followed, which is a violation of Oregon Administrative Rules.

• August 5, 2024: Failed to assure proper hydration Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-057-0160 (Resident Services in a Memory Care Community)
  State’s findings

  The facility failed to provide a daily program for nutrition and hydration available throughout each resident's waking hours and failed to provide and document an individualized nutritional plan for each resident in their service or care plan Per a complaint "residents [were] 'wasting away'... numerous residents upon seeing [visitor] all came swarming [him/her] - hungry, thirsty, as if they hadn't been fed in while.", which is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 43 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.