The nursing home failed to protect residents from abuse and neglect by others. Cited March 2025 — isolated incident, actual harm.
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F-Tag 600 — 42 CFR §483.12 — S/S: G
Nursing home report
MONTROSE SPRINGS SKILLED NURSING & WELLNESS CENTER
MONTROSE, CA · Medicare-certified · 109 beds
Needs attention
For-profitChain member
Data as of September 1, 2026
3 of 5 overall
Montrose Springs Skilled Nursing & Wellness Center has a 3-star overall rating, with weaker health inspection results at 2 stars but strong quality measures at 5 stars. Staffing is slightly below the federal benchmark (3.92 vs. 4.1 hours per resident per day), and it had $32,139 in fines in the last 24 months plus a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.9247 hrs/resident/day
Quality measures
Last inspection: July 23, 2026Penalties, last 24 months: $32,139recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.9247.
Staffing detail
- Registered nurses
- 0.47
- Licensed practical nurses
- 0.88
- Nurse aides
- 2.57
- Weekend nursing
- 3.72
Hours per resident per day.
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
28.6%21.7%Improving
Residents with a fall causing major injury
1.9%0%Improving
Residents with pressure ulcers (bedsores)
2.3%0%Improving
Residents with a urinary tract infection
2.9%2%Improving
Residents who lost too much weight
3.1%10.9%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
2.2%16.3%Worsening
Residents whose ability to walk got worse
0%4.4%Worsening
Long-stay residents on antianxiety or sleep medication
16.7%10.3%Improving
Short-stay residents newly given an antipsychotic
1.8%0%Improving
Residents with a long-term catheter
1.3%0.7%Improving
Residents with new or worsening incontinence
2.6%0%Improving
Residents with depressive symptoms
34%48%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—100%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The nursing home failed to provide the doctor’s immediate care orders when the resident was admitted. Cited May 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 635 — 42 CFR §483.20 — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited July 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited July 2024 — limited pattern, potential for harm.
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F-Tag 755 — 42 CFR §483.45 — S/S: E
The home failed to properly watch nurse aides' work and provide regular training. Cited July 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 730 — 42 CFR §483.35(e)(7) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 5 health deficiencies.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 3 health deficiencies.
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- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
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- INSPECTION
Health inspection found 2 health deficiencies.
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- INSPECTION
Health inspection found 15 health deficiencies.
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- PENALTY
A federal fine of $32,139 was recorded.
- PENALTY
A federal payment denial was recorded.
Penalties & enforcement
On record with Medicare: 1 fine · $32,139 in total fines · 1 payment denial.
- $32,139
Federal fine
Feb 20, 2025
- 6 days
Medicare/Medicaid payment denial
May 10, 2024
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of PACIFIC HEALTHCARE HOLDINGS · 15 homes · 1.9 stars avg
- Occupancy
- 122.3 residents on an average day (112% of 109 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 51 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.