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. Page 1 of 2 056322 056322 05/01/2025 Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered Care Planning revised 11/2018 indicated the facility will ensure that a comprehensive person-centered care plan is developed for each resident. The policy indicated the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. The policy indicated the baseline care plan Summary will be developed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident's admission and it will include, at minimum, the following information necessary on each care plan to properly care for a resident: physician orders and dietary orders. 056322 Page 2 of 2