Starfile / California

MONTROSE SPRINGS SKILLED NURSING & WELLNESS CENTER

2635 HONOLULU AVE, MONTROSE, CA 91020 · CCN 056322

Abuse icon

Inspection history vs California & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$32,139

Number of fines

1

Number of penalties

2

Payment denials

1

Chain

Chain

PACIFIC HEALTHCARE HOLDINGS

Facilities in chain

15

Chain avg overall

2.30 / 5

Inspection citations (80)3 actual harm

1. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2026-01-22 · Health · corrected 2026-02-14

   Potential for more than minimal harm

2. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2026-01-22 · Health · corrected 2026-02-14

   Potential for more than minimal harm

3. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

4. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

5. DF0565Honor the resident's right to organize and participate in resident/family groups in the facility.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

6. DF0578Honor 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.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

7. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

8. DF0688Provide 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.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

9. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-03 · Health · corrected 2025-07-25

   Potential for more than minimal harm

10. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

11. DF0692Provide enough food/fluids to maintain a resident's health.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

12. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

13. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

14. DF0880Provide and implement an infection prevention and control program.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

15. BF0911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.2025-07-03 · Health · corrected 2025-07-25

    Potential for minimal harm

16. BF0912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.2025-07-03 · Health · corrected 2025-07-25

    Potential for minimal harm

17. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2025-07-03 · Health · corrected 2025-07-25

    Potential for more than minimal harm

18. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-05-01 · Health · corrected 2025-05-22

    Potential for more than minimal harm

19. GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-03-28 · Health · corrected 2025-04-05

    Actual harm

20. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-03-28 · Health · corrected 2025-04-05

    Potential for more than minimal harm

21. GF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2025-03-12 · Health · corrected 2025-04-09

    Actual harm

22. DF0660Plan the resident's discharge to meet the resident's goals and needs.2025-02-20 · Health · corrected 2025-03-14

    Potential for more than minimal harm

23. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

24. DF0558Reasonably accommodate the needs and preferences of each resident.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

25. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

26. DF0583Keep residents' personal and medical records private and confidential.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

27. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

28. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

29. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

30. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

31. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

32. DF0697Provide safe, appropriate pain management for a resident who requires such services.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

33. EF0730Observe each nurse aide's job performance and give regular training.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

34. BF0732Post nurse staffing information every day.2024-07-12 · Health · corrected 2024-08-05

    Potential for minimal harm

35. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

36. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

37. EF0759Ensure medication error rates are not 5 percent or greater.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

38. EF0761Ensure 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.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

39. EF0802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

40. EF0803Ensure 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.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

41. DF0880Provide and implement an infection prevention and control program.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

42. BF0911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.2024-07-12 · Health · corrected 2024-08-05

    Potential for minimal harm

43. BF0912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.2024-07-12 · Health · corrected 2024-08-05

    Potential for minimal harm

44. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-07-12 · Health · corrected 2024-08-05

    Potential for more than minimal harm

45. DF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2024-05-17 · Health · corrected 2024-06-14

    Potential for more than minimal harm

46. DF0558Reasonably accommodate the needs and preferences of each resident.2024-05-17 · Health · corrected 2024-06-14

    Potential for more than minimal harm

47. GF0635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.2024-05-10 · Health · corrected 2024-06-03

    Actual harm

48. DF0711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.2024-05-10 · Health · corrected 2024-06-03

    Potential for more than minimal harm

49. DF0558Reasonably accommodate the needs and preferences of each resident.2024-04-09 · Health · corrected 2024-04-29

    Potential for more than minimal harm

50. DF0576Ensure residents have reasonable access to and privacy in their use of communication methods.2024-04-09 · Health · corrected 2024-04-29

    Potential for more than minimal harm

51. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-04-09 · Health · corrected 2024-04-29

    Potential for more than minimal harm

52. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-03-06 · Health · corrected 2024-03-22

    Potential for more than minimal harm

53. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-03-06 · Health · corrected 2024-03-22

    Potential for more than minimal harm

54. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-27 · Health · corrected 2024-03-20

    Potential for more than minimal harm

55. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-11-29 · Health · corrected 2023-12-26

    Potential for more than minimal harm

56. DF0578Honor 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.2023-06-13 · Health · corrected 2023-06-29

    Potential for more than minimal harm

57. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-06-07 · Health · corrected 2023-06-15

    Potential for more than minimal harm

58. DF0610Respond appropriately to all alleged violations.2023-06-07 · Health · corrected 2023-06-15

    Potential for more than minimal harm

59. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-06-07 · Health · corrected 2023-06-15

    Potential for more than minimal harm

60. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2023-06-02 · Health · corrected 2023-06-28

    Potential for more than minimal harm

61. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2023-06-02 · Health · corrected 2023-06-28

    Potential for more than minimal harm

62. DF0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

63. DF0584Honor 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.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

64. DF0644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

65. DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

66. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

67. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

68. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

69. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

70. DF0693Ensure 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.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

71. DF0695Provide safe and appropriate respiratory care for a resident when needed.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

72. DF0698Provide safe, appropriate dialysis care/services for a resident who requires such services.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

73. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

74. DF0759Ensure medication error rates are not 5 percent or greater.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

75. EF0803Ensure 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.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

76. DF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

77. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

78. DF0881Implement a program that monitors antibiotic use.2022-03-24 · Health · corrected 2022-04-26

    Potential for more than minimal harm

79. BF0911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.2022-03-24 · Health · corrected 2022-04-26

    Potential for minimal harm

80. BF0912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.2022-03-24 · Health · corrected 2022-04-26

    Potential for minimal harm

Ownership

Other facilities in MONTROSE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.