Health inspection·October 9, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess, and monitor neuro-checks (a neurologic function assessment tool used to assess and monitor a resident's level of consciousness) on one of four residents (Resident 1), after an unwitnessed fall. Residents Affected - Few This failure had the potential to result in an unassessed altered level of consciousness (ALOC- state of decreased awareness and/or arousability), and delay of treatment for Resident 1. Findings: On August 24, 2023, at 11:10 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. A record review of Resident 1's medical records indicated the resident was admitted to the facility on [DATE], at 6:42 p.m., with diagnoses which included history of falls; syncope (Fainting) and collapse; delirium (Mental state of confusion). Resident 1 had a brief stay, of less than 24 hours at the facility, as she was discharged to the General Acute Care Hospital (GACH) on August 9, 2023, at 3:29 p.m., for re-evaluation of ALOC, following an unwitnessed fall earlier in the day. A review of Resident 1's SBAR - Fall (Situation, Background, Assessment, Recommendation), dated August 9, 2023, at 6:30 a.m., by Licensed Vocational Nurse (LVN) 1, indicated, Resident 1 was heard, Moaning lightly . and found . laying . on her right side (on the floor) at the right of her bed . On August 28, 2023, at 1:51 p.m., an interview was conducted with LVN 2. LVN 2 worked the AM (morning) shift, and she took over Resident 1's care, post unwitnessed fall August 9, 2023. LVN 2 stated the procedure for monitoring a resident who experienced an unwitnessed fall, included initiating and assessing neuro-checks for ALOC, for 72 hours. LVN 2 stated neuro-checks were then filed in the resident's medical records. LVN 2 stated, she remembered monitoring & assessing Resident 1's and completing neuro-checks, throughout her shift on August 9, 2023. However, she was unable to produce a copy of the neuro-check monitoring documentation. On August 28, 2023, at 2:50 p.m., during a concurrent interview with the Director of Nursing (DON), and record review of Resident 1's medical record. The DON verified, if a resident has an unwitnessed fall, the neuro-check assessment would be initiated by staff and monitored for 72 hours. The DON further stated, staff should have initiated neuro-check assessments on Resident 1, after her unwitnessed fall, from the time she was found on the floor, until she transferred out to GACH for assessment of ALOC. The DON verified, she could not locate Resident 1's neuro-check assessments in her medical records, stating, It doesn't look like (the neuro-checks) have been uploaded (to resident's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555403 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555403 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Palms Health Care Center 44610 Monterey Avenue Palm Desert, CA 92260 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)