Inspection Reports for
ManorCare Health Services-Palm Desert

The facility failed to ensure proper implementation of infection control precautions for two residents on droplet precautions, as staff were observed not wearing all required personal protective equipment (gown, gloves, face shield) while providing care, potentially increasing the risk of influenza spread.

The complaint investigation focused on a resident-to-resident abuse incident on November 9, 2025, involving Residents A and B, and a quality of care complaint regarding Resident E's critical low hemoglobin levels and Resident C's delayed orthotic consultation. The investigation found failures in timely reporting, investigation, treatment, and care coordination.

The facility failed to thoroughly investigate and timely report an allegation of resident-to-resident abuse involving Residents A and B, resulting in potential for further abuse. Additionally, the facility failed to provide appropriate treatment and monitoring for Resident E's critical low hemoglobin levels and did not develop a care plan. The facility also delayed ordering an orthotic consultation for Resident C, potentially delaying rehabilitation progress.

The investigation was triggered by a facility reported incident involving delayed response to call lights for Resident 2 and an allegation of abuse for Resident 3. Resident 2 was discharged prior to the investigation. Resident 3 was observed receiving care alone despite care plan requiring two staff, and a skin tear was reported during care.

The facility failed to ensure call lights were answered promptly for Resident 2, with call lights remaining on for extended periods, and failed to implement Resident 3's care plan requiring two staff present during care, resulting in care plan noncompliance and a skin tear injury.

The visit was triggered by complaints regarding infection control practices, specifically related to TB testing and antibiotic use.

The facility failed to ensure tuberculosis (TB) testing was completed and documented according to policy for two residents, and failed to implement an effective antibiotic surveillance program for 11 residents, risking undetected TB transmission and inappropriate antibiotic use.

The investigation was triggered by complaints about the use of bleach products in Resident 1's room despite her repeated requests not to use bleach due to adverse effects, and complaints regarding pharmacy services related to narcotic medication accounting and shift-to-shift narcotic counts.

The facility failed to honor Resident 1's preference to avoid bleach products in her room, resulting in distress and verbal aggression. Additionally, the facility did not follow its policy for narcotic controlled substances accounting, including improper verification of liquid Ativan and missing nurse signatures on shift-to-shift narcotic count sheets.

The complaint investigation was triggered by an allegation of abuse by a Physical Therapy Assistant (PTA) against Resident 2. The allegation was not properly investigated or reported, and the PTA was not suspended. The facility also failed to report the abuse allegation to the California Department of Public Health within required timeframes.

The facility failed to properly investigate and report an abuse allegation made by Resident 2 against the PTA, did not suspend the PTA pending investigation, and failed to provide timely treatment and documentation for Resident 2's skin tear. Additionally, the facility failed to maintain a sanitary environment due to black mold found in Resident 7's shower.

The investigation was initiated due to allegations of financial abuse of Resident 1 by an acquaintance and quality of care concerns for Resident 2, including failure to administer HIV medications and provide restorative nursing services. The complaint was substantiated with findings of failure to report abuse timely and failure to provide ordered care.

The facility failed to timely notify police and Adult Protective Services of suspected financial abuse of a resident, failed to administer HIV medications to a resident for 22 days as ordered by the physician, and failed to provide restorative nursing services as ordered, potentially risking harm to residents. Documentation and communication deficiencies were also noted.

The complaint investigation found that Resident 1 had multiple falls in January 2025, with seven documented fall incidents. The facility's interdisciplinary team did not implement or evaluate elevated fall interventions such as a sitter after the falls. The resident's representative provided a private sitter for two nights, which was effective in preventing falls, but the facility did not provide a sitter thereafter despite responsibility to do so.

The facility failed to ensure the effectiveness of interventions to address multiple falls for Resident 1, who had repeated unwitnessed falls despite existing fall prevention measures. The interdisciplinary team did not evaluate or initiate elevated interventions such as a sitter, which could have prevented further falls.

The facility was found deficient in multiple areas including failure to treat residents with dignity, medication administration errors, inadequate staffing, poor infection control practices, failure to follow dietary and nutrition protocols, unsafe equipment maintenance, and environmental cleanliness issues.

The complaint involved an allegation that RNA 1 squeezed Resident 3's buttocks. The facility was made aware of the allegation on December 3, 2024, but did not report it to the state until December 7, 2024, four days later, violating the facility's process and state regulations.

The facility failed to report an allegation of abuse by the Restorative Nursing Assistant towards Resident 3 to the California Department of Health within the required two-hour timeframe, resulting in a delayed investigation and potential exposure of the resident to further abuse.

The visit was complaint-related due to a reported gastrointestinal outbreak starting November 15, 2024, with 58 residents and 18 staff exhibiting GI symptoms. Isolation precautions were implemented until symptoms resolved for 48 to 72 hours.

The facility failed to ensure proper infection control practices including failure of a CNA to use PPE when providing care to a resident on contact isolation, failure of three direct care staff to perform proper handwashing before and after care, and failure of the Physical Therapy Assistant (PTA) to clean and disinfect the gait belt before and after resident use. These failures had the potential to increase the spread of infections among residents.

The investigation was triggered by a complaint related to quality of care concerning the transfer method of Resident 1. The complaint was substantiated based on interviews and record reviews confirming improper transfer procedures.

The facility failed to transfer Resident 1 via ambulance on an emergent basis despite the resident's unstable health condition, resulting in potential delay in managing respiratory distress symptoms during transport. Interviews and record reviews confirmed the resident was transferred on a non-emergent basis contrary to policy.

The visit was complaint-related, investigating quality care issues concerning falls and the failure to update care plans and conduct post-fall evaluations and interdisciplinary team meetings after two fall incidents involving Resident 1.

The facility failed to reevaluate the risks and effectiveness of interventions to address incidents of falls for Resident 1, who had two falls during her stay. Care plans, post-fall evaluations, and interdisciplinary team meetings were not updated or completed after the falls, which could result in further falls and injuries.

The complaint involved an allegation of abuse where Resident 1 attempted to strike Resident 2 on September 19, 2024, at approximately 2:30 a.m. The facility staff did not report the incident to CDPH, local police, or Ombudsman within the required 2 hours. Interviews with staff and residents confirmed the incident and the failure to report.

The facility failed to report allegations of abuse involving Residents 1 and 2 to the California Department of Public Health within the required 2-hour timeframe, potentially putting residents at further risk. The incident involved Resident 1 attempting to strike Resident 2, who blocked the strike with no injuries reported.

The investigation was triggered by complaints regarding resident rights violations, missed notifications to representatives, failure to hold care conferences, inconsistent code status documentation, missed dialysis notification, unresolved grievance for lost dentures, and failure to provide ordered nutritional supplements.

The facility failed to ensure authorized resident representatives were notified and involved in care planning and changes, failed to hold timely care conferences, had inconsistent code status documentation for one resident, failed to notify a representative of missed dialysis treatment, did not file a grievance for a lost denture, and failed to provide nutritional supplements as ordered to several residents.

The complaint investigation found that Resident A fell during transfer due to CNA not using a gait belt and wheelchair brakes malfunctioning. The fall resulted in injury including genu valgum deformity requiring further surgery. Staff interviews confirmed the CNA was unaware of the resident's fall risk and did not provide required assistance.

The facility failed to provide two-person assist and use a gait belt during transfer of Resident A, resulting in a fall that caused a genu valgum deformity. The wheelchair brakes were not functioning properly, contributing to the fall. Staff interviews confirmed lack of awareness of Resident A's fall risk and failure to follow transfer protocols.

The complaint investigation focused on Resident 1 regarding failure to obtain proper consent for medication, failure to notify the representative of skin condition changes, and inadequate wound care documentation and assessments.

The facility failed to obtain proper treatment consent from the responsible party for a psychotropic medication, failed to notify the resident's representative of changes in skin condition, and failed to conduct consistent and documented weekly skin assessments including wound measurements for three sampled residents, potentially delaying appropriate treatment.

The complaint involved misappropriation of property (financial abuse) reported on May 15, 2024, regarding unauthorized charges on Resident 1's debit card. The Social Service Assistant delayed reporting the allegation to CDPH until May 14, 2024, which was 14 days after becoming aware of the issue. The complaint was substantiated with findings of delayed reporting and lack of resident monitoring.

The facility failed to timely report an allegation of financial abuse within two hours to the California Department of Public Health after becoming aware of the allegation. Additionally, the facility failed to monitor and assess the resident for emotional and psychosocial effects following the abuse allegation.

The complaint involved allegations of financial abuse reported by Resident 1, which were substantiated by interviews and record reviews showing failure to notify law enforcement. The investigation also included a resident-to-resident altercation involving Residents 1 and 2, highlighting failures in monitoring and supervision.

The facility failed to notify law enforcement of financial abuse allegations involving Resident 1, increasing the risk of further abuse. Additionally, the facility failed to provide dedicated 1:1 sitter monitoring for Residents 1 and 2, and failed to obtain a physician order for 1:1 monitoring for Resident 2, resulting in both residents sharing one sitter during an altercation that caused injury.

The complaint investigation was substantiated based on observations, interviews, and record reviews indicating Resident 2 was left unsupervised despite a physician's order for a sitter, resulting in an altercation with another resident.

The facility failed to ensure adequate supervision for Resident 2, who required close monitoring and was left unsupervised during care, leading to a resident-to-resident altercation. The lack of staff presence violated the physician's order for a sitter and facility protocol.

The complaint investigation found substantiated issues including lack of background check for a CNA, missing care plan for psychotropic medication for a resident, and missing physician visit documentation for several months for the same resident.

The facility failed to perform a background check for a direct care employee prior to employment, failed to develop a care plan with interventions for psychotropic medications for a resident, and failed to ensure the resident was seen by a physician or designee every 30 days as required. These failures had the potential to expose residents to abuse, neglect, and inadequate care.

The visit was complaint-related, investigating a quality of care issue concerning the failure to provide a trapeze device as ordered. The deficiency was substantiated with findings that the order was not communicated or acted upon.

The facility failed to ensure that Resident 1 received a trapeze as ordered by the physician on March 29, 2024. Licensed nurses did not communicate the order to maintenance or physical therapy, resulting in no trapeze installation and potential limited mobility for the resident.

The complaint investigation was substantiated as the facility did not report the abuse allegation within the required 2-hour timeframe. The Social Service Director, Director of Nursing, and Registered Nurse all acknowledged the delay in reporting.

The facility failed to report an allegation of physical abuse within 2 hours to the California Department of Public Health as required. Interviews with staff confirmed delays in reporting and issues with faxing the allegation to the authorities.

The visit was complaint-related, triggered by concerns about admission and discharge notification practices. The complaint was substantiated by findings that the facility did not notify the Ombudsman of discharges for 30 residents and failed to provide required notices.

The facility failed to provide a copy of the written notice of transfer or discharge to the long-term care Ombudsman for 30 of 50 discharged residents, contrary to facility policy. Interviews and record reviews confirmed the absence of documented notices of transfer/discharge and inconsistent notification practices.

The facility failed to provide repositioning for one sampled resident (Resident 1) as required, which had the potential to result in a pressure-related skin injury. Observations and interviews revealed that Resident 1 was not offered repositioning consistently despite facility policy requiring repositioning every two hours.

The visit was complaint-related, investigating quality-of-care issues including skin evaluation, pressure ulcer care, and nutritional assessment. The complaint was substantiated as failures were confirmed in these areas.

The facility failed to conduct a skin evaluation on admission, delayed treatment for non-pressure skin injuries and pressure ulcers, and did not complete nutritional assessments or weekly weights as required. These failures placed Resident 1 at risk for infection, complications, and compromised nutrition.

The facility failed to complete the quarterly MDS assessment for one of three sampled residents, specifically missing the September 2023 section C assessment, which could delay assessment of residents' needs and monitoring of their progress.

The investigation was triggered by a complaint alleging sexual abuse of Resident A by a Hospice Nurse. The allegation was substantiated by interviews and record reviews indicating the abuse occurred and was not reported within the required two-hour timeframe.

The facility failed to timely report an allegation of sexual abuse within two hours to the California Department of Public Health, and failed to ensure Resident A was regularly assessed and treated for constipation as ordered while receiving hospice care. These failures had the potential to cause further harm to Resident A's physical, emotional, and psychosocial wellbeing.

The investigation was complaint-related, triggered by a quality care issue regarding failure to report a COVID-19 outbreak. The complaint was substantiated as the facility did not report the outbreak to CDPH.

The facility failed to report an outbreak of COVID-19 to the California Department of Public Health (CDPH), resulting in a delay in investigation. Eight residents and five staff tested positive for COVID-19 starting September 19, 2023, but only the local county health department was notified, not CDPH.

The visit was complaint-related, investigating a quality care issue regarding failure to report a COVID-19 outbreak. The complaint was substantiated as the facility did not report the outbreak to CDPH.

The facility failed to report an outbreak of COVID-19 to the California Department of Public Health (CDPH), resulting in a delay in investigation. Eight residents and multiple staff tested positive for COVID-19 starting September 19, 2023, but only the local county health department was notified, not CDPH.

The complaint investigation found that Registered Nurse 2 did not report allegations of abuse for Resident 1 and Resident 2 within the required two-hour period. Interviews with the Director of Nursing and facility Administrator confirmed the policy requiring immediate reporting. RN 2 acknowledged the failure to report timely. The incidents involved a third-party sitter's aggressive behavior towards Resident 1 and an allegation of spousal abuse involving Resident 2's family member.

The facility failed to report allegations of abuse within the required two-hour timeframe to the California Department of Public Health for two residents. This failure had the potential to result in further abuse affecting the residents' physical, emotional, and psychosocial well-being.

The visit was complaint-related, investigating a patient's rights concern about the call light system volume. The complaint was substantiated as the call light volume was found to be too low and was subsequently corrected.

The facility failed to ensure the call light alarm volume was audible enough to alert staff when residents called for assistance, potentially delaying needed care. The call light volume was initially too low but was adjusted to a higher volume during the investigation.

The complaint investigation focused on missing advance directives for Residents 11, 41, and 55, and inadequate management of wandering behavior for Resident 11. The Social Service Designee confirmed the absence of advance directives in the records. Observations and interviews confirmed Resident 11's wandering behavior was not assessed, monitored, or communicated to the physician.

The facility failed to ensure that copies of advance directives were available in the medical records for three residents, potentially preventing staff from honoring residents' medical treatment wishes. Additionally, the facility failed to assess, monitor, and notify the physician regarding wandering behavior of one resident, which posed a risk of injury.

The facility had multiple deficiencies including failure to maintain advance directives in resident records, incomplete implementation of care plans especially related to repositioning and range of motion exercises, medication management issues including expired and discontinued medications not removed, inadequate monitoring of psychotropic medications, failure to follow dietary orders and menus, infection control lapses, and insufficient staff in-service training.

The complaint investigation was triggered by an allegation of sexual abuse reported on March 14, 2023. The allegation involved a night shift nurse allegedly grazing Resident A's private parts. The facility was aware of the allegation around 12 p.m. on March 16, 2023, but failed to report it to CDPH within two hours as required.

The facility failed to report the allegation of sexual abuse within the required two-hour timeframe to CDPH, resulting in a delay of approximately seven hours. This failure had the potential to cause further harm to Resident A's physical, emotional, and psychosocial well-being.

The visit was complaint-related, investigating an accident involving Resident A who left the facility without staff awareness. The complaint was substantiated by observations, record reviews, and staff interviews.

The facility failed to ensure that when the alarm was triggered, staff checked that no resident left the building. Resident A, who had severe cognitive impairment and elopement risk, left the facility unnoticed, increasing risk of accidents. Interviews with staff confirmed the alarm was reset without verifying the resident's whereabouts, contrary to facility protocol.

The facility failed to administer intravenous antibiotic medications as prescribed for 2 of 3 sampled residents, resulting in late medication administration without proper documentation or physician orders for the delays. The Director of Nursing acknowledged the lack of notes explaining late doses and referenced facility policy and state regulations requiring timely medication administration.

The complaint investigation found that Resident 1's physical therapy was discontinued due to insurance issues, and the facility did not provide restorative nursing assistant services. The resident and family expressed concerns about lack of therapy and progress. The managed care organization discontinued therapy due to lack of progress, but the facility does not have RNA services to support the resident. The resident was eligible for 100 days of skilled coverage but therapy was stopped after about two weeks.

The facility failed to provide rehabilitation services to Resident 1 when physical therapy was discontinued due to insurance issues, and no restorative nursing assistant (RNA) services were provided to maintain the resident's functional level. This failure had the potential to cause a decline in the resident's optimal level of function.

The complaint was received on December 29, 2022, regarding an alleged physical abuse incident on December 15, 2022, involving Resident 1 and CNA 1. The allegation was investigated and found unsubstantiated.

The facility failed to report the alleged abuse to the California Department of Public Health within two hours as required. The investigation found the allegation unsubstantiated, with no physical injuries observed on Resident 1 and no further documentation of the abuse allegation or investigation summary.

The facility was found deficient in multiple areas including resident dignity and respect, advance directive documentation, beneficiary notice, care planning, discharge planning, activities of daily living assistance, skin care, hearing aid follow-up, restorative nursing services, bowel and bladder care, respiratory care, dialysis care, dementia care, food safety, and infection control practices.