Health inspection·July 1, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had a comprehensive, person-centered care plan created for known behaviors related to the diagnosis of dementia.During the investigation, Resident 1 had known behaviors that included noncompliance with safety interventions, such as the resident's inability to consistently remember to use the call light and repeated attempts to get out of bed or chair without seeking staff assistance. Despite a documented history of three prior falls, Resident 1's care plans lacked individualized interventions and measurable goals to effectively manage Resident 1's behaviors. This failure has further potential to result in a decline in the resident' physical and psychosocial well- being due to the lack of individualized and effective care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted the resident on 11/26/2025, with a diagnosis of dementia (a decline in mental ability such as memory, and problem solving, making it hard to perform everyday task and activities.During a review of Resident 1's care plan titled Non - Compliance with Care - I am at risk for health conditions not being treated or managed because I refuse to use call light to ask for assistance and remove my tab alarm, dated 3/1/2024, the care plan goal included to comply with the facility's policy and protocols and physician's orders. The care plan Interventions included documenting of resident's noncompliance as needed and to respect her right to refuse.During a review of Resident 1's Minimum Set Data ( MDS- a federally mandated resident assessment tool) dated 5/28/2025, the MDS indicated Resident 1 is not cognitively intact (has difficulty with short-term memory, attention, or decision - making). The MDS indicated Resident 1 also required the use of a walker and wheelchair for mobility and requires steadying with contact guard assistance as resident completes activities such as transfer to toilet or chair to bed activities.During a review of Resident 1's History and Physical ( H&P), dated 6/24/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Medication Administration Record ( MAR) for the month of June 2025, the MAR indicated Resident 1 received Tramadol HCL (an opioid analgesic - used for moderate to severe pain) oral Tablet 50mg on the following dates:- - 6/14/2025 at 11:30AM for Pain of 9 out of 10 on pain scale- -6/19/2025 at 05:30AM for Pain of 7 out of 10 on pain scale- -6/19/2025 at 3:50PM for Pain of 8 out of 10 on pain scale- -6 /20/2025 at 1:38PM for Pain of 8 out of 10 on pain scale- -6/21/2025 at 11:05 PM for Pain of 6 out of 10 on pain scale-6/22/2025 at 10:30PM for Pain of 6 out of 10 on pain scale- -6/23/2025 at 12:15 PM for Pain of 9 out of 10 on pain scale- -6/29/2025 at 9:21PM for Pain of 6 out of 10 on pain scaleDuring a review of Resident 1's Fall Risk assessment dated 2/28/ 2025, the record indicated Resident 1 had a fall risk score of 24. The record indicated a score higher than 18 is considered High Risk and a care plan will be developed to reduce falls and injuries. There were no further care plan revised or developed for Resident 1's high fall risk assessed on 2/28/2025. During a review of Resident 1's Radiology Results Report, dated 6/14/2025, the report indicated the (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: 055135 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 055135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020 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)