Inspection Reports for
Cottages at Palm Springs

The complaint investigation was substantiated. Allegations included staff neglect causing a broken femur, failure to seek medical treatment, and failure to notify the POA of the resident fall. The resident sustained an unwitnessed fall on 2023-01-28, was not medically evaluated until 2023-02-02, and the POA denied being notified by the facility. An immediate civil penalty of $500 was assessed, with additional penalties pending review.

The investigation substantiated that staff neglect resulted in Resident 1 sustaining a broken femur due to improper bed rail positioning. Staff failed to seek timely medical treatment for the resident, with medical evaluation occurring five days after the fall. Additionally, the licensee did not notify the resident's POA of the fall incident, despite claims to the contrary.

The complaint alleged that Resident #1 sustained multiple wounds and skin tears due to staff neglect. The resident received home health, hospice, and wound care specialist services. Despite multiple wounds and pressure injuries documented, the investigation found no preponderance of evidence to substantiate the allegation. The resident passed away on 2024-01-31 and was unable to be interviewed.

The investigation, which included observations, interviews, and records review, found the allegation unsubstantiated due to insufficient evidence to prove the alleged violation occurred.

The complaint was substantiated. The resident sustained an arm fracture due to neglect/lack of care and supervision. Staff left the resident unattended on the toilet, resulting in a fall and fracture. Medication was discontinued without a formal physician's order, and staff failed to seek timely medical treatment for stroke symptoms, resulting in delayed care and serious injury.

The investigation substantiated that the resident sustained an arm fracture due to staff neglect and lack of supervision, including leaving the resident unattended on the toilet leading to a fall. The allegation that staff did not ensure toileting assistance was unsubstantiated. The allegation that medications were not properly dispensed was substantiated due to medication discontinuation without formal physician order and failure to seek timely medical treatment for stroke symptoms. An immediate civil penalty of $500 was assessed, with potential additional penalties pending review.

The complaint investigation was substantiated for allegations that staff did not abide by the admission agreement, failed to provide adequate transportation for residents' scheduled appointments, did not timely repair the facility vehicle, and did not ensure resident laundry needs were met. Other allegations about incident reporting, care and supervision, and staffing sufficiency were unsubstantiated.

The investigation substantiated allegations that staff failed to provide transportation and laundry services as required by the admission agreement, including the facility bus being out of service for two months and laundry services being skipped during staff vacation. Other allegations regarding incident reporting, care and supervision, and staffing levels were unsubstantiated.

The complaint was substantiated. The allegation was that staff did not assist a resident with incontinence needs, resulting in the resident being unattended for over 20 hours and bedding soaked with urine or seepage from a wound. The investigation included observations, interviews, and record reviews confirming the allegation.

The investigation substantiated the allegation that Resident #1 was not attended to for over 20 hours and their bedding was soaked with unknown liquid. The facility revised the resident's care plan to increase checks to every hour. The deficiency posed health and safety risks and was cited under California Code of Regulations 87625(b)(3).

The complaint investigation was substantiated for the allegations that the shower/tub was not kept in a state of repair and the shower seat was loose and not fixed properly. The food quality complaint was unsubstantiated.

The investigation substantiated the allegations regarding the shower/tub disrepair and loose shower seat, posing a potential personal rights risk to residents. The food quality complaint was unsubstantiated as most residents reported the food was of the right temperature and alternatives were available.