Montrose Springs Skilled Nursing & Wellness Center
MONTROSE SPRINGS SKILLED NURSING & WELLNESS CENTER in MONTROSE, CA — inspection on February 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 2/24/2026 at 5:06 PM with License Vocational Nurse (LVN 1) stated that according to the facility's protocol, when a resident sustained a fall with injury, the physician and family must be notified, the care plan gets revised and a post-fall assessment is completed.
During an interview on 2/24/2026 at 5:30 PM with the Director of Nurses (DON), the DON stated that there was no documented evidence that Resident 2's physician, and family had been notified after the resident's fall on 2/18/2026.
The DON stated the physician must be made aware of significant changes in order to give medical treatment.
During an interview on 2/26/2026 at 5:45 PM with the Director of Nurses (DON), the DON stated that the RNA should have communicated and documented the resident's ROM exercises refusals, with the charge nurse, or supervisor of not doing the ROM and ambulation exercises so that Resident 2's physician could have been notified.
During a review of the facility's policy and procedure (P&P) titled Change of Condition Notification revised 8/25/2022, the P&P indicated that the facility will promptly inform the resident's physician and interested family member when the resident endures a significant change in their condition caused by an accident.
During a review of the facility's policy and procedure (P&P) titled Restorative Nursing Program Guidelines, revised 1/30/2026, the P&P indicated that the RNA will carry out the restorative program according to the care plan and will document the amount of time spent in the activity and the tolerance to the program.
056322 02/26/2026
Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020
resident's plan of care will be updated as necessary to reflect the interventions to meet the resident
assessment and document these preferences in the medical record and include them in the resident's
056322 02/26/2026
Montrose Springs Skilled Nursing & Wellness Center 2635 Honolulu Ave Montrose, CA 91020
During a review of Resident 1's admission Record, dated 2/6/2026, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, Malignant neoplasm of the large intestine and rectum (Cancer of the large intestine and rectum).
During a review of the Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 2/13/2026, the MDS indicated the resident's cognition (thought process) is moderately impaired and required supervision on eating, and oral hygiene.
Partial/moderate assistance in upper body dressing, and substantial/maximal assistance in toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear.
During a review of Resident 1's Telephone/Verbal Orders dated 2/7/2026 Glipizide oral tablet 2.5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount).
Metformin HCL tablet 500 mg one tablet by mouth two times a day for Diabetes with meals.
Fasting blood sugar before breakfast at 6:30 AM and at bedtime 9:00 PM.
Call the physician if blood sugar is less than 70 or more than 400.
During a review of Resident 1's Care Plan for Diabetes dated 2/7/2026, the care plan indicated that the resident will be free from any signs and symptoms of hypoglycemia.
During a review of Resident 1's Medication Administration Record dated 2/7/2026 fasting blood sugar before breakfast and scheduled at 6:30 AM and bedtime at 9:00 PM.
The order indicated to call the physician if the blood sugar is less than 70 or higher than 400.
The MAR further indicated no blood sugar was done prior to administering medications for one day on 2/7/2026 at 6:30 AM.
Continued review of the MAR indicated Resident 1 received Metformin (medication that treats high blood sugar) 500 mg twice a day with meals at 9:00 AM and Glipizide (medication that treats high blood sugar) 2.5 mg one tablet at 9:00 AM on 2/7/2026.
During an interview on 2/26/2026 at 5:45 PM with the Director of Nurses (DON), DON stated that the blood sugar should have been checked in the morning prior to medication administration as ordered by the physician and if it was not marked in the MAR it was because it was not done stated that when the order was enter it was timed to begin at 9:00 PM and not before breakfast.
During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 6/26/2025, indicated that when medication is dependent upon vital signs or testing the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record for example the point of care blood glucose.