Inspection citations
1’23
32’24
20’25
32’26
85 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 24, 2026 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Jul 24, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Jul 24, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jul 24, 2026 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Jul 24, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 24, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jul 24, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jul 24, 2026 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jul 24, 2026 | E · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jul 24, 2026 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jul 24, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jul 24, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 24, 2026 | E · potential | Dispose of garbage and refuse properly. | Routine |
| Jul 24, 2026 | E · potential | Provide or get specialized rehabilitative services as required for a resident. | Routine |
| Jul 24, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jul 24, 2026 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jul 24, 2026 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jul 23, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Jul 23, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jul 23, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 23, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Jul 23, 2026 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Complaint |
| Jul 1, 2026 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Jul 1, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 1, 2026 | D · potential | Provide timely, quality laboratory services/tests to meet the needs of residents. | Complaint |
| Apr 20, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 7, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 26, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 26, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Feb 26, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 22, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 22, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jul 3, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jul 3, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Jul 3, 2025 | D · potential | Honor the resident's right to organize and participate in resident/family groups in the facility. | Routine |
| Jul 3, 2025 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Jul 3, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 3, 2025 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jul 3, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 3, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jul 3, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jul 3, 2025 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Jul 3, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 3, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 3, 2025 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jul 3, 2025 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jul 3, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| May 1, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Mar 28, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 28, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 12, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 20, 2025 | D · potential | Plan the resident's discharge to meet the resident's goals and needs. | Complaint |
| Jul 12, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jul 12, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jul 12, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Jul 12, 2024 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Jul 12, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 12, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jul 12, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jul 12, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jul 12, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jul 12, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Jul 12, 2024 | E · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Jul 12, 2024 | B · minimal | Post nurse staffing information every day. | Routine |
| Jul 12, 2024 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Jul 12, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jul 12, 2024 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jul 12, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jul 12, 2024 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Jul 12, 2024 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Jul 12, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 12, 2024 | B · minimal | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Routine |
| Jul 12, 2024 | B · minimal | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jul 12, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| May 17, 2024 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| May 17, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| May 10, 2024 | G · harm | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Complaint |
| May 10, 2024 | D · potential | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Complaint |
| Apr 9, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Apr 9, 2024 | D · potential | Ensure residents have reasonable access to and privacy in their use of communication methods. | Complaint |
| Apr 9, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Mar 6, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Mar 6, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Feb 27, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 29, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Montrose Springs Skilled Nursing & Wellness Center
2635 Honolulu Ave, Montrose, CA 91020 · (818) 248-6856
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056322
- Certified beds
- 109
- Legal owner
- Verdugo Valley Skilled Nursing & Wellness Centre, LLC
- Part of
- Pacific Healthcare Holdings
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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