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
2 of 5 overall
Montrose Springs Skilled Nursing & Wellness Center has a 2-star overall rating, with 2 stars for health inspections, 1 star for staffing, and 5 stars for quality measures. It has $32,139 in fines in the last 24 months and a recent federal penalty, with recent inspection citations involving abuse/neglect protections, admission doctor’s orders, and food handling standards.
Facility ratings
Health inspections
Staffing
Quality measures
Last inspection: February 26, 2026Penalties, last 24 months: $32,139recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports not reported.
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
20.4%Worsening
Residents with a fall causing major injury
1.1%Improving
Residents with pressure ulcers (bedsores)
4.6%Improving
Residents with a urinary tract infection
1.8%Improving
Residents who lost too much weight
7.6%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
5.2%Worsening
Residents whose ability to walk got worse
4.5%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
15.8%Worsening
Short-stay residents newly given an antipsychotic
1.7%Worsening
Residents with a long-term catheter
1.2%Steady
Residents with new or worsening incontinence
3%Improving
Residents with depressive symptoms
38.6%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
100%Steady
Short-stay residents given the pneumonia vaccine
100%Steady
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.
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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
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 15 health deficiencies.
See what inspectors found
- 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
- 122.6 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.