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, (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 04/19/2024 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)