Health inspection·January 22, 2026

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 interview and record review, the facility failed to ensure a comprehensive, resident-centered care plan entailed specific objectives and interventions to provide adequate care for one (1) of five (5) sampled residents, (Resident 5), who continuously refused medications even after educational risk were provided from 12/1/25 to 1/23/26. This deficient practice had the potential to cause a negative outcome to residents' health condition.During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE]. The admitting diagnoses included but not limited to: atherosclerotic heart disease (a heart disease caused by plaque buildup in arterial walls), hypertensive heart disease with heart failure (a disease occurs when chronic high blood pressure causes the heart muscle to thicken and stiffen, limiting its ability to fill or pump blood effectively), cardiomyopathy (chronic disease of the heart muscle), and type 2 diabetes mellitus (a type of chronic condition with high blood sugar). During a review of Resident 5's Physician's Orders, the Orders details indicated Resident 5 had 15 active medications; 14 out of 15 medications were oral medications and 1 was a topical patch (a medicated, sticky patch applied to the skin that delivers a specific dose of medicine directly into the bloodstream over time, bypassing the digestive system for a slow, steady release). The 14 oral medications included 3 medications to treat high blood pressure and various heart diseases, 2 medications to treat or prevent blood clots, 5 vitamins and supplements, 1 as needed pain medication, 1 stool softener, 1 laxative, and 1 medication to prevent stomach upset caused by stomach acid. The topical patch was clonidine (medication to treat high blood pressure) 0.1 milligrams (mg, an unit to measure mass) per 24 hours transdermal (through the skin) patch, apply 1 patch on every Wednesday, ordered on 7/3/2025. During an observation on 01/22/2026 at 3:08 PM, Resident 5 was observed sleeping in bed. During a review of Resident 5's Care Plan for episodes of refusing medications, initiated on 6/30/25, revised on 7/29/25 and 10/14/2025, the Care Plan did not indicate new interventions for when Resident 5 refused medications. This care plan had four interventions, and all were initiated on 6/30/2025. The interventions included: assess the resident's reason for refusing medications, document all refusals and reasons and action taken, encourage to take medication as ordered and explained risks and benefits, and notify MD for complications. During a review of Resident 5's Physician Notes from 1/1/ 2025 to 1/22/2026, the Notes indicated the following:On 01/11/2025 and 5/28/2025 indicated Resident 5 tolerated medications and denied any complaints. The Physician Notes datedOn 7/11/2025 indicated Education provided to [Resident 5] regarding the importance of complying to medication to avoid complications associated with elevated [blood pressure (BP)]. [Resident 5] verbalized understanding and refused all medication except clonidine.On 9/25/2025 and 10/28/2025 indicated Resident 5 was noncompliant with BP medication except clonidine patch and unwilling to comply to medication. The physician notes datedOn 11/27/2025 indicated Resident 5 was noncompliant with BP checks at times and continued to be noncompliant (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 3 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 01/22/2026 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)