Public Record
Montrose Springs Skilled Nursing & Wellness Center
Operated by Pacific Healthcare Holdings
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 109
- Avg. residents per day
- 122.6
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 83
- Fire safety findings
- 7
- Inspections on file
- 21
- Last inspection
- 2026-02-26
*CMS
*CMS
*CMS
*CMS
Citations
83 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0688Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0578Generalpotential for harm
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.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0912Generalno actual harm
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0911Generalno actual harm
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0552Generalpotential for harm
Ensure that residents are fully informed and understand their health status, care and treatments.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0600Seriousactual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0600Seriousactual harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0660Generalpotential for harm
Plan the resident's discharge to meet the resident's goals and needs.
- 0803Generalpotential for harm
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.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0761Generalpotential for harm
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.
- 0802Generalpotential for harm
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0911Generalno actual harm
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- 0912Generalno actual harm
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0557Generalpotential for harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0635Seriousactual harm
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
- 0711Generalpotential for harm
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0576Generalpotential for harm
Ensure residents have reasonable access to and privacy in their use of communication methods.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0578Generalpotential for harm
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.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0745Generalpotential for harm
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- 0911Generalno actual harm
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0912Generalno actual harm
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0803Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0693Generalpotential for harm
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.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0584Generalpotential for harm
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.
- 0557Generalpotential for harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection3 deficiencies
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT…
Read full statement of deficiencies - Inspection2 deficiencies
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - View inspection reportInspectionFire Safety2 deficiencies
- Inspection15 deficiencies
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide one…
Read full statement of deficiencies - Inspection1 deficiency
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - Inspection2 deficiencies
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record…
Read full statement of deficiencies - Inspection1 deficiency
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interviews, and record reviews, the facility failed to implement the facility's policy…
Read full statement of deficiencies - Inspection1 deficiency
F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide…
Read full statement of deficiencies - View inspection reportInspectionFire Safety3 deficiencies
- Inspection22 deficiencies
F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on…
Read full statement of deficiencies
Showing the 10 most recent inspections. 11 earlier inspections are also on record.
Ownership
Pacific Healthcare Holdings
15nursing homes nationwide, in CMS records
FAQ
Questions and answers
- What is Montrose Springs Skilled Nursing & Wellness Center?
- Montrose Springs Skilled Nursing & Wellness Center is a Medicare- and Medicaid-certified nursing home in Montrose, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 056322.
- What is the CMS rating for Montrose Springs Skilled Nursing & Wellness Center?
- Montrose Springs Skilled Nursing & Wellness Center has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Montrose Springs Skilled Nursing & Wellness Center have?
- Montrose Springs Skilled Nursing & Wellness Center is certified for 109 beds. It serves an average of 122.6 residents per day.
- How many citations does Montrose Springs Skilled Nursing & Wellness Center have?
- Montrose Springs Skilled Nursing & Wellness Center has 83 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Montrose Springs Skilled Nursing & Wellness Center last inspected?
- Montrose Springs Skilled Nursing & Wellness Center was last inspected on February 26, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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