Health inspection·May 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plan was initiated to indicate Resident 1 ' s current therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) ordered for nothing by mouth (NPO). This deficient practice had the potential for Resident 1 to not receive specific care and services specific to Resident 1 ' s needs in accordance to the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered Care Planning. Findings: A review of Resident 1 ' s admission Record [AR] indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included adult failure to thrive (a decline in an adult ' s physical and mental state) and Alzheimer ' s disease (a brain disorder that destroys memory and thinking skills). A review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) dated 4/26/2025, the HPE indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Telephone Orders dated 4/24/2025, indicated an order for NPO, due to Resident 1 not being able to swallow food or medications. A review of Resident 1 ' s active Care plans, the care plans did not indicate Resident 1 was NPO. During a concurrent interview and record review on 4/30/2025 at 2:45PM with Registered Nurse (RN1) 1, Residents 1 ' s Care Plans were reviewed. RN 1 stated that Resident 1 did not have a care plan to address her NPO status. RN 1 stated that Resident 1 was NPO upon admission since Resident 1 was unable to swallow any food or liquids. RN 1 stated Resident 1 was at high risk for aspiration (food or fluids entering the airway) and that if Resident 1 received any food or fluid by mouth, the food or liquidcould enter her lungs and cause Resident 1 to choke. During a concurrent interview and record review on 4/30/2025 at 4 PM, with the Director of Nursing (DON), Resident 1 ' s Care Plans were reviewed. DON stated that Resident 1 did not have a care plan to address her NPO status. DON stated that his nursing staff should have initiated a care plan to address Resident 1 NPO status immediately to avoid Resident 1 being given any food or fluids that could potentially cause harm. (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: 056322 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 056322 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave 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)