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A middle-range Medicare rating. Review each component and visit in person before deciding.
based on 72 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Montrose Springs Skilled Nursing & Wellness Center has a middle-range Medicare overall rating. Strengths include compassionate rehabilitation and physical therapy staff. Some reviewers note concerns about loss or theft of residents' personal clothing (mentioned by 3 reviewers). Review the health-inspection, staffing, and quality-measure components separately, then visit in person.
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
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Concerns
Rating Trends
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Distribution · 80 analyzed
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 .”
“My sis in law, loves it there, she's safe and clean. Above and beyond care🫶🏼”
“My husband’s clothes was stolen. Try to contact the administrator Ani, she never returned my calls.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
11
measures
5
measures
1
measures
Residents with depression symptoms
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
Residents whose walking got worse
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents needing more daily help over time
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
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.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
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.
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.
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.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
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.
Environmental Deficiencies
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Federal Penalties
Fine
Feb 20, 2025
$32,139
Payment Denial
May 10, 2024
6-day denial
Montrose Springs Skilled Nursing & Wellness Center
for profit
Pacific Healthcare Holdings
15 facilities nationwide
Chain avg rating: 2.3/5 · Rank 6 of 15
Owners
Pacific Healthcare Holdings, INC.
Owner · Organization
Key personnel
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