Matthew Draxton
(Update: Adding video)
BEND, Ore. (KTVZ) — In the fall of 2024, KTVZ’s Problem Solvers broke the story of a resident at Aspen Ridge Memory Care facility passing away after being left in the sun on a hot August day. This spawned a multi-part series, investigating claims made by former staff and resident familiy members of alleged abuse and neglect.
Less than a year later, and only a month after Oregon state agencies removed licensing restrictions, a second heat-related incident occurred at the same facility, now known as Desert Sage.
Fortunately, though, this patient survived.
“Were you surprised when an incident occurred just one month after the state left?” KTVZ’s Matthew Draxton asked former caregiver Audrianna George.
She responded: “I was not surprised at all.”
On July 14th, 2025, 90-year-old resident Dorris Howard fell in the courtyard at Desert Sage Memory Care during a day of very high temperatures in Bend. According to a family member, it was 20 minutes before anyone found her.
“I think the high temperatures in the Bend area around 94, 95 degrees that day,” said Fred Steele, the director of the Oregon Office of Long-Term Care Ombudsman.
According to a family member close to Howard, her legs had been sunburned and she had a temperature read of 100.5 degrees by the time she arrived at the hospital
“Would you say it was preventable?” Draxton asked George. She responded: “Yes, I would say it was very much preventable. I would say it was very much negligence on the caregivers’ part.”
George is a former caregiver at Desert Sage Memory Care, formerly Aspen Ridge Memory Care, and worked closely with Howard. She worked at Aspen Ridge from 2022 to 2023, and then again from January 2025 to June 2025, meaning she was present during the management change.
According to the Oregon Department of Human Services, Howard had previously been determined to be a fall risk, and was supposed to have safety checks every hour by staff, as stated in her care plan.
“She was left a lot to wander around, especially outside. She loved to go outside,” George explained. She continued, “A couple of times, the doors would be left open. If you’re going to do that, you need to keep a close eye on what’s outside.”
ODHS found that facility had failed to provide a safe environment, due to a lack of safety checks and because she was not properly supervised
Speaking from her experience as a caregiver at the facility, George claims, “No one was paying attention. I noticed a lot of people on their phones, and it was a huge worry.”
Desert Sage Memory Care, formerly known as Aspen Ridge, was on a licensing restriction since September 13th, 2024, according to ODHS, due to the August 30th death of a resident.
KTVZ’s Problem Solvers reported last year that the resident was left in the sun in 97-degree weather for two hours while wearing a winter fleece.
“The initial reaction was, ‘How did this happen again at the same facility?’” questioned Steele. He continued, “I mean, clearly, there’s a concern with the setup at that facility.”
The managmenet company at the tine of the 2024 incident was Frontier Senior Living.
George claims, “They kind of would turn a blind eye to the problems at hand.”
By February, though, Areté Living, a new management company, took over and renamed it Desert Sage Memory Care.
Areté Living released a statement to KTVZ’s Problem Solvers, saying,”A recent incident at our community has been linked by the state to a separate matter involving the previous operator last year. This association was made based on preliminary information that has not yet been thoroughly investigated or finalized.”
“We remain confident that the completed investigation will show our community has operated fully in accordance with Oregon’s rules, regulations, and quality standards — as we have consistently done throughout Areté Living and Avamere’s long history of service in the state of Oregon.”
“Although the current situation is a setback and premature comparisons have been made to a former operator, we are proud of the high standards of care, transparency, and meaningful improvements we have consistently delivered to this community.”
“It is a new day at Desert Sage Memory Care, and we stand by the exceptional work our team continues to deliver,” the statement concluded
George claims she was “really excited” when Areté Living took over. However, she says, “Not even a month into being with the new management, things were no different. In fact, some of it (was) even worse.”
George claims other caregivers were neglectful and abusive to residents.
“Residents are being left in the same clothes for weeks., she said. “Residents are being overdosed with meds. Residents are not being given meds, the proper meds and-or meds at all. And it’s been put in the computer that they have been.”
George also alleges staff were rough with residents, specifically when trying to get them to use the restroom. “They would like slam them down on the toilet and just like hold them there and not just let them go at their own pace.”
In spite of this, George says things were different during ODHS inspections. She said caregivers were “instructed what we could and couldn’t say, what we could and couldn’t do,” and “everybody was just on their best behavior.”
The 2025 investigation found staffing to be an issue leading to a lack of oversight. In order to remove the licensing condition, the facility needed to ensure suffice staffing through the day and that caregivers are trained caregivers, not facility staff covering for them.
They were also required to do 30-minute courtyard checks, as well as detail resident visits to the courtyard, including when they entered, left, and the state of condition residents were in when in the courtyard.
Another requirement was reviewing care plans for residents who consistently utilize the courtyard.
But George said after they would pass inspection, “or state wouldn’t be there, things would just fall back into the same old same old.”
Desert Sage Memory Care ultimately had their restrictions lifted on June 4th after ODHS found the facility to be in “substantial compliance,” according to ODHS records.
The state agency specifically noted: “Systems are in place to ensure similar deficiencies do not reoccur.”
Ironically, Steele said, “Within a month of ODHS not providing their regulatory day-to-day oversight that they were with that condition in place, another incident occurs,”
George added that if “you’re not sincere or passionate about what you do and you put on a show, the quality of care, it’s never going to last long.”
Desert Sage Memory Care is now under a new set of conditions as of August 1st ,2025. That includes limited admission, with only one resident allowed every seven days, each of whom must be approved by oversight. The courtyard must be monitored every 15 minutes and staff must submit regular updates to ODHS.
ODHS will also be conducting bi-weekly check-in, and written reports are to be given to the state agency every seven days.
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