Montrose Springs Skilled Nursing & Wellness Center
2635 Honolulu Ave · Montrose, CA · 91020 · 8182486856
109 certified beds For profit - Limited Liability company Chain: Pacific Healthcare Holdings
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- 3 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 1 · $32,139 |
Inspection citations (85 in the current record)
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Potential for harm · D April 20, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected May 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D April 7, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has no plan of correction · Quality of Life and Care
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Potential for harm · D February 26, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected March 20, 2026 · Resident Rights
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Potential for harm · D February 26, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 20, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 26, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 20, 2026 · Quality of Life and Care
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Potential for harm · D January 22, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 14, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 22, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 14, 2026 · Pharmacy Service
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Potential for harm · D July 3, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 25, 2025 · Resident Rights
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Potential for harm · D July 3, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 25, 2025 · Resident Rights
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Potential for harm · D July 3, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected July 25, 2025 · Resident Rights
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Potential for harm · D July 3, 2025
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.
Corrected July 25, 2025 · Resident Rights
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Potential for harm · D July 3, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 3, 2025
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.
Corrected July 25, 2025 · Quality of Life and Care
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Potential for harm · D July 3, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected July 25, 2025 · Quality of Life and Care
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Potential for harm · D July 3, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected July 25, 2025 · Quality of Life and Care
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Potential for harm · D July 3, 2025
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected July 25, 2025 · Quality of Life and Care
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Potential for harm · E July 3, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 25, 2025 · Nutrition and Dietary
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Potential for harm · D July 3, 2025
Provide and implement an infection prevention and control program.
Corrected July 25, 2025 · Infection Control
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Potential for harm · D July 3, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected July 25, 2025 · Environmental
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Potential for harm · D July 3, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 25, 2025 · Quality of Life and Care
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No harm found · B July 3, 2025
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Corrected July 25, 2025 · Environmental
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No harm found · B July 3, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected July 25, 2025 · Environmental
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Potential for harm · D May 1, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 22, 2025 · Resident Assessment and Care Planning
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Actual harm · G March 28, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 28, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 20, 2025 | Fine | $32,139 |
| May 10, 2024 | Payment Denial | 6 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056322 · certified since December 23, 1974. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.