Montrose Springs Skilled Nursing & Wellness Center
Montrose Springs Skilled Nursing & Wellness Center is a 2-star rated nursing home in Montrose, CA with 109 beds. CMS sub-ratings: health inspections 2/5, staffing 1/5, quality measures 5/5.
The facility has 134 health violations on record. Federal fines total $120,834 across 8 enforcement actions. Most recent inspection: May 1, 2025.
Data synthesized from CMS.gov and California public inspection records. Reviewed by Christopher F. Nesbitt, Sr., NR-EMT & BU-trained Paralegal.
Inspection History Overview
Data current as of May 6, 2026 · Source: CMS Provider Data
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2025 1 penalties totaling $49,445
Fine
2022 1 penalties totaling $1,988
Fine
2021 4 penalties totaling $4,581
Fine
Fine
Fine
Fine
2020 2 penalties totaling $64,820
Fine
Fine
Health Violations by Year
2025 5 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Plan the resident's discharge to meet the resident's goals and needs.
2024 32 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Observe each nurse aide's job performance and give regular training.
Post nurse staffing information every day.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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.
Provide and implement an infection prevention and control program.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
2023 7 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Respond appropriately to all alleged violations.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
2022 23 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Implement a program that monitors antibiotic use.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
2021 3 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide and implement an infection prevention and control program.
2020 6 violations
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.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide and implement an infection prevention and control program.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2019 20 violations
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Ensure each resident receives an accurate assessment.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Have policies on smoking.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2018 21 violations
Have a program that investigates, controls and keeps infection from spreading.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that residents are fully informed and understand their health status, care and treatments.
Reasonably accommodate the needs and preferences of each resident.
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.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Honor each resident's preferences, choices, values and beliefs.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
2017 17 violations
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.
Maintain comfortable and safe temperature levels.
Keep all essential equipment working safely.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Reasonably accommodate the needs and preferences of each resident.
Conduct initial and periodic assessments of each resident's functional capacity.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Provide bedrooms that hold no more than 4 residents per room.
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Frequently Asked Questions About Montrose Springs Skilled Nursing & Wellness Center
- What violations has Montrose Springs Skilled Nursing & Wellness Center received?
- Montrose Springs Skilled Nursing & Wellness Center has 134 health and safety violation(s) documented by CMS inspections. All violation data comes from official Medicare inspection reports and is updated regularly from government sources.
- What is the quality rating of Montrose Springs Skilled Nursing & Wellness Center?
- Montrose Springs Skilled Nursing & Wellness Center has a 2-star rating out of 5 from CMS. This rating indicates the facility may have quality concerns that should be investigated further. The rating is based on health inspections, staffing levels, and quality measures.
- When was Montrose Springs Skilled Nursing & Wellness Center last inspected?
- Inspection reports are documented by state survey agencies and the Centers for Medicare & Medicaid Services (CMS). Reports typically lag 2-3 months behind the actual inspection date. Visit the facility's full profile page for detailed violation information and inspection history.
- Is Montrose Springs Skilled Nursing & Wellness Center safe?
- Safety at Montrose Springs Skilled Nursing & Wellness Center should be evaluated based on multiple factors: the facility's CMS rating, recent violation history, and personal visits. We recommend reviewing the complete inspection history, speaking with current residents and families, consulting healthcare professionals, and visiting in person before making placement decisions.
- How do I contact Montrose Springs Skilled Nursing & Wellness Center?
- Phone: (818) 248-6856. Address: 2635 Honolulu Ave, Montrose, CA. For visiting hours and admission information, call the facility directly.
- What services does Montrose Springs Skilled Nursing & Wellness Center offer?
- Montrose Springs Skilled Nursing & Wellness Center is a skilled nursing facility with 109 beds. The facility accepts Medicare and Medicaid. For specific services like rehabilitation, memory care, or short-term recovery, contact the facility directly.
- What are better facilities near Montrose, CA?
- Compare Montrose Springs Skilled Nursing & Wellness Center with other nursing homes in Montrose, CA on our facilities page. Filter by star rating, bed count, and recent inspection results to find the best match for your needs.
Compare Nursing Homes in Montrose, CA
| Facility | Rating | Violations | Beds |
|---|---|---|---|
| Montrose Springs Skilled Nursing & Wellness Center (this facility) | ★★☆☆☆ | 134 | 109 |
| Montrose Healthcare Center | ★★★★☆ | 0 | 59 |
| Montrose Healthcare Center | ★★★★☆ | 83 | 59 |
| Verdugo Valley Skilled Nursing & Wellness Ct | ★★☆☆☆ | 0 | 138 |
Editorial Standards & Data Oversight
Data Source: This report is based on official public inspection records from the Centers for Medicare & Medicaid Services (CMS) Provider Data Catalog.
Editorial Process: Content generated using AI to synthesize complex regulatory data, then reviewed and verified for accuracy by our editorial team.
Professional Review: All content undergoes standards and compliance oversight by Christopher F. Nesbitt, Sr., Nationally Registered EMT & BU-trained Paralegal, using professional regulatory data auditing protocols.
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