Desert Sage Retirement Community

Last inspection

February 4, 2026

Inspections

6, 30 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

6

Regulatory actions

1

Fines assessed

$4,875.00 (6 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• December 2, 2024 to September 9, 2025: License Condition, Failed to provide safe environment ALFCD24-00866; incident: CALMS - 00066825
  Based on the violations above, ODHS concludes that Respondents acts or omissions create a situation that necessitates ODHS to issue a license condition. That is because the number of citations found during the survey cycle places residents at risk for harm.
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)

Inspections

• February 4, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• October 30, 2024: Change of Owner, 19 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  Show all 21

  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0282: RN Delegation and Teaching severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0361: Acuity Based Staffing Tool - Elements severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0612: General Building: Floors severity level 2, scope L2 Widespread
• August 20, 2024: Complaint Investig., 3 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• March 28, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 19, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 4, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected February 4, 2023
• November 1, 2021: Validation, 6 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected December 15, 2021
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected December 15, 2021
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected December 15, 2021
  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected December 15, 2021
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern, corrected December 15, 2021
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected December 15, 2021

Substantiated abuse or neglect

• September 18, 2024: Failed to provide service 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a resident of the facility and completely dependent on facility staff for his/her care, as AV is bed bound. AV requires incontinence checks, cleaning of his/her room and is supposed to receive physical therapy regularly to re-gain the ability to walk and/or move him/herself. AV's therapy was canceled and no staff had any answer as to why this occurred. According to documentation, AV is not checked regularly for incontinence and has been in wet/soiled incontinence garments for up to 10 hours. AV's room has been noticed to not be cleaned regularly by visitors of AV. Recently, AV's room was deep cleaned. The facility's failure to provide services is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 5, 2024: Failed to provide safe environment 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)
  State’s findings

  On or about September 5, 2024, Alleged Perpetrator 2 (AP2) verbally abused Alleged Victim (AV) by making degrading comments about AV's room and blaming AV for the loss of his/her personal property when AV confronted AP2 about his/her missing personal property. AP2 spoke with AV in a loud tone as a result of AV's confrontation. At time of incident, AP2 was working at the facility as a caregiver for residents including AV. Based on facility documentation and interviews, AP2's response and behaviors towards AV was degrading, particularly criticizing the cleanliness of AV's room, accusing AV of hoarding, and blaming AV for the removal on his/her personal items. AP2's actions constitutes verbal abuse. The facility failed to follow proper procedures and communication regarding AV's clothing removal, contributed to the escalation of tensions between AV and staff, which led to emotional distress and conflict. The facility's failure to resolve AV's clothing issue, compounded by the turnover in management, led to an escalation of tensions, resulting in the verbal/emotional distress experienced by AV. The facility's failure to provide a safe environment for AV is considered which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 12, 2024: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to appropriately care plan related to the Alleged Victim's (AV) fall history. AV suffered two falls in June 2024, one of which resulted in a fractured sacrum. AV began showing signs of dehydration, weakness, and difficulty with ambulation at the end of June 2024 and the beginning of July 2024. On July 8, 2024, AV was evaluated for a change of condition due to significant weight loss. AV had suffered three more falls in July 2024 before passing away on July 16, 2024. AV fell a total of five times between June 6, 2024, and July 13, 2024. Based on facility documentation and interviews, the facility failed to provide oversight and monitoring of AV's change of condition by failing to ensure AV's service plan was reflective of AV's care needs due to AV's health decline and increased fall risk. The facility's failure caused AV to suffer avoidable pain and unreasonable discomfort over time, which is a serious violation of resident rights, is considered neglect of care and constitutes abuse.

• July 9, 2024: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) resided in the Assisted Living facility and required staff assistance with eating and medications. AV had a personal care giver who assisted AV with eating, however, this caregiver took ill on June 25, 2024 and facility staff needed to assist AV with eating. On or about July 8, 2024, there was observed to be 5 full plates of uneaten food in AV's kitchen. The last documented assistance with feeding AV was on July 7, 2024 at 11:27 AM. It is unknown if AV was provided meals or food after that time. AV was moved to another facility on July 9, 2024 and continued to eat double portions of food daily for two weeks. AV was also observed to have concerning hygiene when he/she arrived at the new facility. On July 8, 2024, AV missed two daily doses of his/her medication which controls head dyskinesia, making it difficult for AV to eat without the medication. The faciilty's failure to ensure AV was fed, had proper hygiene, and proper medication administration is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 30, 2023: Failed to assure timely medical treatment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
  State’s findings

  On or about December 30, 2023, the Alleged Victim (AV) suffered an unwitnessed fall in the facility. On or about January 3, 2024, a nursing assessment recorded that AV exhibited bruising draining downward and will still tender in the right rib area. AV stated multiple times over several days that AV wanted to go to the hospital for rib pain, however, AV was told he/she appeared to be fine and was not sent out. From December 31, 2023 to January 8, 2024, AV was seen by staff, and expressed pain by clutching their ribs and crying out with substantial movement. The facility took no action to provide medical care for AV during this time, leaving AV in continued pain and unreasonable discomfort for over a week. On or about January 8, 2024, AV called emergency services from his/her phone and was transported to the hospital AV was diagnosed with multiple broken ribs, a collapsed left lung and approximately one liter of fluid had to be drained from his/her lung. AV was hospitalized for 6 days. The facility's failure to provide timely medical treatment is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 25, 2023: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) had a private caregiver that assisted him/her at the facility. AV was care planned to have facility staff care for AV. According to staff statements and documentation AV's private caregiver would not allow staff to assist AV with ADL's, such as showers, personal hygiene, laundry and cleaning AV's apartment, leaving AV dirty and with matted hair. The facility failed to intervene on AV's behalf to ensure his/her safety and that he/she was receiving the care needed. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• September 3, 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

  On or about September 3, 2025, Alleged Perpetrator 2 (AP2) engaged in inappropriate physical contact with Alleged Victim (AV), a resident of the facility. Based on facility documentation and interviews, AV and AP2 had a close, friendly relationship. AV would invite AP2 into AV's apartment and they would watch TV together. At time of incident, AV initially consented when AP2 asked if AP2 could kiss AV. Once things started going further, AV got nervous and asked AP2 to stop and leave, which AP2 did. AP2 asked AV not to tell anyone about what happened which triggered AV's past sexual abuse trauma history. Although AP2 ended the inappropriate physical contact with AV, AP2's actions are considered an inappropriate violation of professional boundaries between caregiver and resident and is considered sexual abuse due to inappropriate sexual contact with a resident in the facility. AP2's actions constitutes sexual abuse. The facility failed to protect AV from sexual abuse which is a violation of Oregon Administrative Rules.

• October 1, 2024: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
  State’s findings

  on or about September 24, 2024, the Alleged Victim (AV) reported to Alleged Perpetrator #2 (AP2), along with two other staff that he/she likely had a UTI and had for a while. AP2 told Witness #1 IW1) and Witness #2 (W2) that he/she planned to get AV tested for a UTI. On September 25, 2025, AP2 told APSS that AV needed to be sent out to the hospital for a urine analysis, for suspected UTI. On or about October 1, 2024, W1 returned to the facility and learned that AV had never been sent out or tested for UTI. AV was still complaining of the UTI, was in pain and not at baseline. AP2 never followed up on AV's complaints, did not complete an RN assessment, did not contact AV's PCP, POA or the hospital, nor did AP2 enter any of this information into the facility system. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a change of condition was addressed and monitored is a violation of Oregon Administrative Rules.

• September 30, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  An investigation determined the facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. AV did not suffer a negative outcome as result of missing medications; however, the facility failed to ensure a safe medication administration system by failing to ensure staff are properly trained to complete refill orders. The facility's failure is violation of Oregon Administrative Rules.

• August 12, 2024: Failed to provide appropriate housekeeping services Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to ensure the implementation of services per resident service plan per complaint that housekeeping is not being done, which is a violation of Oregon Administrative Rules.

• August 12, 2024: Failed to assure adequate food supply Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0030 (Resident Services)
  State’s findings

  The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week per complaint that resident choices are not being honored the facility is serving the same food options over and over, which is a violation of Oregon Administrative Rules.

• February 1, 2024: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this 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 95 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.