Health inspection·April 19, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when two out of five residents (Residents 1 and 5), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. Residents Affected - Few This failure had the potential for delayed medical management and unmet care needs. Findings: On April 19, 2024, at 11:09 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On April 19, 2024, at 11:24 a.m., Resident 1 was observed lying in bed. During a concurrent interview, Resident 1 stated she was able to get up to the bathroom with staff assistance. Resident 1 stated she would press the call light to get assistance from staff. Resident 1 stated sometimes call light response was over 30 minutes and sometimes up to an hour, usually on the evening or night shifts. Resident 1 stated staff usually came to assist her, but they did not come one evening. Resident 1 stated she did not make it to the bathroom in time, and she soiled herself. Resident 1 stated she was embarrassed and humiliated that she did not get to the bathroom in time. On April 19, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included glioblastoma (a malignant brain tumor), left sided hemiplegia (paralysis effecting one side of the body), and muscle wasting. Resident 1's Physician Order Summary indicated Resident 1 had capacity to make decisions. Resident 1's Bowel and Bladder Assessment dated April 4, 2024, at 10 p.m., indicated, .Bowel .Usually Continent (aware of the need to use the bathroom to void or have a bowel movement) .Cognitive Skills .Independent-Alert And Oriented . On April 19, 2024, Resident 5's medical record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a lung condition that makes breathing difficult), muscle wasting, and congestive heart disease (the heart does not pump blood effectively). Resident 5's Physician History and Physical indicated Resident 5 had capacity to make decisions. On April 19, 2024, at 1:55 p.m., Resident 5 was observed sitting on her bed, finishing her lunch meal. During a concurrent interview, Resident 5 stated call light response could be up to 30 minutes sometimes. Resident 5 stated she and Resident 1 would time the call light response and write it down, Page 1 of 2 555403 555403 04/19/2024 Monterey Palms Health Care Center 44610 Monterey Avenue Palm Desert, CA 92260

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and some responses were at one hour. Resident 5 stated call light response was longer on the evening or night shifts. At 2 p.m., Resident 5 was observed pushing her call light, a light was observed illuminated outside the room. At 2:10 p.m., Physical Therapy Assistant (PTA) 1 was observed entering the room. PTA 1 stated she did not enter the room for the call light but to assist Resident 5 with scheduled therapy. On April 19, 2024, at 2:10 p.m., Certified Nursing Assistant (CNA) 1 was observed entering Resident 1 and 5's room. During a concurrent interview, CNA 1 stated he had come to answer the call light (10 minutes after the call light was activated). CNA 1 stated it was important to answer the call lights timely to prevent accidents or falls, and to assist with resident needs. CNA 1 stated 10 minutes was too long for the call light to be answered by staff. CNA 1 stated residents should be assisted up to the bathroom if able. CNA 1 stated a resident might be embarrassed or humiliated by soiling themself when they were able to go to the bathroom. On April 19, 2024, at 2:13 p.m., a follow-up interview was conducted with PTA 1. PTA 1 stated call lights needed to be answered timely and in less than 5 minutes to prevent falls and accidents, and to assist with resident needs. PTA 1 stated the call light should have been answered timely and not 10 minutes after it was pushed. PTA 1 stated Resident 1 was aware of when she needed to use the bathroom and should be encouraged to get up. PTA 1 stated Resident 1 would probably be humiliated and embarrassed if she was not able to get to the bathroom timely and soiled herself. On April 19, 2024, at 2:16 p.m., an interview was conducted with CNA 2. CNA 2 stated she provided care to Resident 1 and 5 but was busy with other residents when the call light was activated. CNA 2 stated all staff were responsible for answering the call lights not just the CNAs. CNA 2 stated call lights should be answered timely and before 5 minutes to prevent accidents, falls, and to assist with resident needs. CNA 2 stated Resident 1 was young and alert and knew when she needed to go to the bathroom but needed assistance from staff. CNA 2 stated Resident 1 could be humiliated if she had soiled herself because she did not make it to the bathroom timely. On April 19, 2024m at 2:20 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated call lights should be answered as soon as possible and within 3-5 minutes. RN 1 stated it was unacceptable for a continent resident to soil themselves because staff did not answer a call light timely to assist. RN 1 stated a resident could feel embarrassed and their dignity could be affected by soiling themselves. Review of the facility document titled, Call Lights-Answering Of undated, indicated, .Facility Staff will provide an environment that helps meet the Resident's needs .Respond to Resident's call light in a timely manner . Review of the facility document titled, Resident Rights undated, indicated, .The resident has a right to a dignified existence . 555403 Page 2 of 2