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Nursing HomeMedicaid Investigative

Montrose Springs Skilled Nursing & Wellness Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2635 Honolulu Ave, Montrose · Montrose, CA 91020109 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 72 Google reviews

5
4
3
2
1
Montrose Springs Skilled Nursing & Wellness Center Nursing Home in Montrose, CA — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Above-median deficiencies (21 vs median 13.0)

Below average in CA · Below recommended RN staffing · Chain outperformer · $32,139 in fines · Abuse citation

Source: Medicare data

What this means for your family

This facility offers excellent physical therapy and a clean environment for rehabilitation. However, families should exercise extreme caution regarding the security of personal belongings and verify that management is responsive to your specific concerns regarding care oversight.

Google Reviews

Google Reviews

72 reviews on Google
Families considering Montrose Springs will find a polarizing environment where many praise the compassionate rehabilitation and physical therapy teams. However, significant concerns exist regarding administrative responsiveness, potential theft of personal belongings, and inconsistent nursing care during off-hours.

Quality Themes

Tap a score for details
Food4.0Staff5.0Clean6.0ActivitiesN/AMedsN/AMemoryN/AComms3.0ValueN/A

Strengths

  • Compassionate rehabilitation and physical therapy staff
  • Clean and organized facility environment
  • Attentive and friendly front desk/reception
  • Effective communication regarding changes in patient condition

Concerns

  • Loss or theft of residents' personal clothing (mentioned by 3 reviewers)
  • Unprofessional or unresponsive administration/management (mentioned by 3 reviewers)
  • Inconsistent nursing responsiveness/staffing levels (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'17(2)'19(6)'23(4)'25(34)'26(5)

Distribution · 80 analyzed

5
52
4
4
3
1
2
0
1
23

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard great things about your physical therapy team; could you tell us more about how the rehab process works for new residents?
  • 2What specific steps are in place to ensure that residents' personal belongings and clothing are kept safe and organized?
  • 3How does the nursing team ensure consistent communication with families when there are any changes in a resident's health or condition?
  • 4Could you describe the current dining experience and what improvements are being made to the meal service and variety?
  • 5What is the protocol for handling medical emergencies or urgent care needs during the overnight hours?
  • 6What kind of daily activities or social events are planned to keep residents engaged and connected with one another?

Personalized based on this facility's data


Key Review Excerpts

The place is very clean and organized and the staff is great at what they do . Whenever there is any issue or change in my mom’s condition they call me right away and it is very much appreciated .

Rehab patient's family · 2025★★★★★

My sis in law, loves it there, she's safe and clean. Above and beyond care🫶🏼

Long-term resident's family · 2025★★★★★

My husband’s clothes was stolen. Try to contact the administrator Ani, she never returned my calls.

Long-term resident's family · 2025☆☆☆☆
Source: 72 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

9

measures

Worse Than Avg

6

measures

Mixed Results

2

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility38.6%
Worse than Avg
Here
38.6%
US
12.1%
CA
7.0%
Los angeles
8.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility3.0%
Better than Avg
Here
3.0%
US
19.4%
CA
10.7%
Los angeles
9.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility4.5%
Better than Avg
Here
4.5%
US
15.3%
CA
10.5%
Los angeles
9.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility5.2%
Better than Avg
Here
5.2%
US
14.4%
CA
10.4%
Los angeles
12.5%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility20.4%
Worse than Avg
Here
20.4%
US
15.5%
CA
11.7%
Los angeles
11.4%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Los angeles
99.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
79.8%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
CA
94.2%
Los angeles
94.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.7%
Worse than Avg
Here
1.7%
US
1.6%
CA
1.5%
Los angeles
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

22deficiencies
2penalties
Above state avg (15.4)
30 complaint-triggered
$32,139 in fines

This facility shows a concerning pattern of protection failures with families filing multiple complaints about resident abuse and neglect, including recent incidents in March 2025. The most recurring issues involve care planning, medication management, and resident rights violations. While all 87 deficiencies across 17 surveys show correction dates, the high volume of complaint-driven investigations (25 deficiencies) and repeated problems in core care areas suggest ongoing challenges with consistent quality care and resident safety.

Apr 20, 2026Complaint
1
0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Apr 7, 2026Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Feb 26, 2026Complaint
3
0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Jan 22, 2026Complaint
2
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Jul 3, 2025Routine
16
0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0565Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0745Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0911Minimal · PatternCorrected

Environmental Deficiencies

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

0912Minimal · PatternCorrected

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Jul 3, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Feb 20, 2025

$32,139

Payment Denial

May 10, 2024

6-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Montrose Springs Skilled Nursing & Wellness Center

Organization Type

for profit

Chain Affiliation

Chain Name

Pacific Healthcare Holdings

Chain Size

15 facilities nationwide

Chain avg rating: 2.3/5 · Rank 6 of 15

Ownership & Management

Owners

Pacific Healthcare Holdings, INC.

Owner · Organization

88%

Key personnel

Rechnitz, ShlomoOfficer / DirectorCorporate Interface Services LLCManagerRockport Administrative Services, LLCManagerAghajanyan, AniManagerKarakashian, GaroManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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