Home / California / Montrose
2635 Honolulu Ave, Montrose, CA 91020 · Los Angeles County · (818) 248-6856
109 certified beds, about 122 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1974
CMS Care Compare ratings, data as of September 1, 2026 · CCN 056322 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 3, 2025, inspectors cited 15 health deficiencies (the California average is 15.6, the national average 9.2).
Of 87 health citations since March 2022, 3 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $32,139 in the last three years; the largest was $32,139, and the latest is dated February 20, 2025.
Nurses and nurse aides worked 3.92 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
CMS links it to Pacific Healthcare Holdings, an affiliated group of 15 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 87 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed for one of three sampled residents (Resident 1) following a significant change in the residents' condition, including significant weight loss and loss of the ability to ambulate. This deficient practice resulted in an inaccurate Minimum Data Set (MDS) for Resident 1, placing the resident at risk for receiving care and services that did not reflect Resident 1's current clinical condition.
Inspectors wroteBased on observation, interview and record review the facility failed to revise and update resident care plan (CP) for one of three sampled residents (Resident 1) when resident had a change of diet texture. This failure had the potential to result in inaccurate provision of services related to the resident's nutritional needs and swallowing status.
Inspectors wroteBased on interview and record review the facility failed to monitor blood glucose levels for one of three sampled residents (Resident 1) who had diagnosis of Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) had glucose (simple sugar - the body's primary source of energy from food) monitored when Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was administered twice a day for 12 days and had physician order with parameters (limits) to hold insulin if glucose was less than 70. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) who was admitted to the facility with an indwelling urinary catheter (tube inserted into the bladder to drain urine) received care and services in accordance with physician orders, by failing to follow-up on a physician ordered for a urology consultation. This deficient practice placed Resident 1 at risk for delayed evaluation and treatment of urinary conditions, prolonged use of the indwelling urinary catheter, urinary tract infection, catheter-related complications, urinary function, and avoidable decline in health status.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a speech therapy evaluation for one of three sampled residents (Resident 1) after speech therapist (ST) 2 identified that Resident 1 had difficulty eating and prior to downgrading Resident 1's diet consistency. This deficient practice had the potential to result in Resident 1 experiencing inadequate nutritional and fluid intake, unintended weight loss, dehydration, and decline in overall nutritional status due to the lack of a timely speech therapy evaluation to determine the most appropriate diet consistency.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote one of two sampled residents' (Resident 1) right to self determination (refers to a person's ability to make choices and direct their own behavior based on their own interests, values, and goals) and to be free from interference (any action by facility staff that improperly hinders or undermines a resident's ability to make decisions, express preferences, or refuse care). On 5/15/2026, between 2:30 to 3:00 PM, Licensed Vocational Nurse (LVN) 1, Certified Nurse Assistant (CNA) 1, and CNA 2 transferred Resident 1 from his bed using a Hoyer Lift to take him to the Shower Room, despite the resident's repeated verbal objections due to pain and discomfort. [...]
Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement Resident 1's care plan interventions to notify the Director of Nursing (DON) to assist with negotiating care when one of two sampled residents (Resident 1) refused incontinence care, get out of bed, and to be cleaned in the Shower Room. LVN 1, CNA 1, and CNA 2 transferred Resident 1 with a Hoyer lift from the bed to a shower chair and transported the resident to the Shower Room without a physician's order or care plan direction, despite the resident's repeated verbal objections due to pain and discomfort on 5/15/2026. As a result of the deficient practice, on 5/16/2026 at 6:47 PM (27 hours 47 minutes from the time Resident 1 complained of discomfort during the Hoyer Lift transfer) Resident 1 requested transfer to a General Acute Care Hospital (GACH) due to severe lower back pain. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 3's physician order for a skin scraping and specimen collection was communicated to the laboratory on 6/18/2026, for one of two sampled residents (Resident 3), who was suspected of scabies and required confirmation of diagnosis, in accordance with the facility's policy and procedure titled Laboratory Services. This deficient practice had the potential to result in delayed or inaccurate diagnosis and treatment of Resident 3's skin condition, increased risk of medication related adverse effects, and increased risk of transmission of scabies within the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for two of four sampled residents (Resident 1 and Resident 2) by failing to record intravenous (IV, liquids administered directly into a vein to rapidly hydrate the body, replace electrolytes, or deliver medication and nutrition) medication administration. This deficient practice had the potential to lead to medication errors, inability to monitor therapeutic responses, and potential adverse outcomes.
Inspectors wroteBased on interview and record review, the facility failed to ensure a 72-hour neurological check (neurocheck, a comprehensive assessment of the functions of brain and body) was continuously conducted and documented for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Fall Management Program after Resident 1 sustained an unwitnessed fall on 3/29/26. This deficient practice had the potential to place Resident 1 at risk for missed detections of neurological deterioration and delayed interventions which could lead to serious health compilations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the attending physician and the responsible party for one of two sampled residents (Resident 2) after Resident 2 sustained a fall with a resulting laceration to the forehead on 2/18/2026. In addition, Resident 2 did not receive range of motion (ROM-movement of the joints) exercises on 2/23/2026, 2/24/2026, 2/25/2026, and 2/26/2026 as ordered by the physician. Staff reported that the resident refused the exercises due to feeling ill; however, the physician was not notified of these refusals. This deficient practice had the potential to delay timely clinical evaluation and treatment, which may lead to worsening of the injury, inadequate pain management, and delays in updating the plan of care, thereby placing the resident at risk for avoidable complications. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a plan of care was developed and implemented to provide effective communication with the language that the resident was able to understand for two of two sampled residents (Resident 1 and 2). This deficient practice prevented the residents from communicating with the staff and had the potential to delay receiving appropriate care/treatment the residents needed. 1. During a review of Resident 1's admission Record, dated 2/6/2026, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, Malignant neoplasm of the large intestine and rectum (Cancer of the large intestine and rectum). [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure 1 out of 2 sampled residents (Resident 2) received treatment and care in accordance with the physician's order by failing to monitor the resident's blood glucose level on 2/7/2026 at 6:30 AM, as required prior to administering hypoglycemic oral medications. This deficient practice had the potential to cause Resident 2 to experience a hypoglycemic (low blood sugar) episode. During a review of Resident 1's admission Record, dated 2/6/2026, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, Malignant neoplasm of the large intestine and rectum (Cancer of the large intestine and rectum). [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, resident-centered care plan entailed specific objectives and interventions to provide adequate care for one (1) of five (5) sampled residents, (Resident 5), who continuously refused medications even after educational risk were provided from 12/1/25 to 1/23/26. This deficient practice had the potential to cause a negative outcome to residents' health condition. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was originally admitted to the facility on [DATE]. The admitting diagnoses included but not limited to: [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration process (med pass, the process of preparing and administering medications to residents) observed, for one (1) of one resident (Resident 1), was performed in the right time. Resident 1 received 7 medications more than 1 hour after the scheduled time. This deficient practice had the potential of medication error (wrong time) that may or may not affect resident's health condition.
Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility's policy and procedure on Dry Goods Storage Guidelines to ensure safe and sanitary food storage in the kitchen where several food items were stored in the dry storage area with no opened date. In addition, one bag of dried cheese powder, dated 3/28/2025, exceeded storage period and was stored in the dry storage area. This deficient practice had the potential to result in harmful bacteria growth that could lead to foodborne illness (any illness resulting from the consumption of contaminated food or beverages) in 113 out of 117 residents who receive food from the kitchen.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of eight (8) sampled residents (Resident 56) with respect and dignity during mealtime, when Certified Nurse Assistant (CNA) 3 was observed standing over Resident 56 while providing feeding assistance. This failure had the potential to result in negatively affecting Resident 56's self-esteem and self-worth.
Inspectors wroteBased on interview, and record review, the facility failed to obtain an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of two sampled resident (Resident 52) who was prescribed Ativan (a psychotropic medication used for anxiety). This deficient practice violated Resident 52's rights to be informed when choosing the type of care or treatment to be received, making decisions on alternative measures that the resident or responsible party preferred, which can negatively affect Resident 52's quality of life.
Inspectors wroteBased on interview, and record review the facility failed to provide prompt efforts to resolve grievances for one of two sampled residents (Resident 107) who voiced to the facility during the Resident Council Meetings to provide a follow-up or a resolution for Wi-Fi extenders (a device that helped extend the range of your existing Wi-Fi network) because it was for the resident's phone and television to work correctly. This deficient practice resulted in unresolved grievance for Resident 107 that affects the residents the resident's quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directives Acknowledgement Form (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life-Sustaining Treatment (POLST, medical order forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) were obtained and readily accessible in the residents' hard copy medical records for one of three sampled residents (Resident 34). [...]
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual for two of four sample residents (Resident 43 and 27) by failing to: 1. Develop a care plan to address interventions for Resident 43's abdominal pain on 3/25/2025. 2. Develop a care plan for Resident 27's to address interventions for medication side effects and behavior monitoring for poor impulse control which was prescribed Depakote (an antiepileptic medication used to reduce excessive electrical activity in the brain believed to cause mood fluctuations in bipolar disorder [sometimes called manic-depressive disordered; mood swings that range from the lows of depression to elevated periods of emotional highs]). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pillows or wedges for body support to help one of four sampled residents (Resident 54) who was quadriplegic (complete immobility due to severe disability from injury to the brain or spinal cord) to achieve the desired comfort and position as indicated in the resident's care plan and the facility's policy and procedures. These deficient practices had the potential for Resident 54 to develop pain, discomfort and contracture (a permanent tightening of muscles, tendons, skin, or other tissues, causing joints to shorten and become stiff, thus limiting normal movement) negatively affect the residents' physical comfort and psychosocial well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled, Fall Management Program and Fall Prevention and Management Program for two of four sampled residents (Resident 106 and Resident 27) by: 1. Failing to provide appropriate and sufficient supervision for Resident 106 by failing to: a. Implement Resident 106's Risk for Falls Care Plan interventions to not leave Resident 106 unattended when toileting. b. Update Resident 106's Fall Risk after falling on 6/24/2025 as indicated in the facility's P&P titled, Fall Prevention and Management Program. c. Document interventions recommended by the Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goal of the resident) after Resident 106's fall on 6/24/2025. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent urinary tract infections (UTI- an infection in the bladder [a hollow, stretchy organ in the lower part of your abdomen that stores urine before it leaves your body]/urinary tract) by assessing the urine for cloudiness, color, sediments (the matter that settles to the bottom of a liquid), blood, odor, and amount of urine output for one of three sampled residents (Resident 2) with foley catheter (an indwelling device that drains urine from urinary bladder into a collection bag outside of body). This deficient practice had the potential for Resident 2 to develop UTI and receive delayed or no treatment for could lead to a decline in the resident's well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate nutritional care and services to one of five (5) sampled residents (Resident 117) based on the comprehensive assessment when Certified Nurse Assistant (CNA) 5 failed to assist Resident 117, who required moderate assistance (helper less than half the effort) during mealtime. This failure had the potential to result in Resident 117 not being provided the proper nutritional care and services consistent with the resident's comprehensive assessment which may lead to decreased appetite and sensation for thirst and could result in unplanned weight loss, dehydration, and the inability to maintain the highest practicable level of well-being.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social service to assist one of four sampled resident (Resident 91), who had no teeth and loose-fitting dentures, by failing to follow up and make an appointment with the dentist. This deficient practice resulted in Resident 91 not utilizing the facility provided dentures and leaving Resident 91 unable to eat well that could lead to weight loss and negatively impacting the resident's quality of life and well-being.
Inspectors wroteBased on observation, interview and record review, the facility failed to enforce the facility's policy and procedure on infection control related to a safe, sanitary environment by failing to: 1. Ensure that Certified Nurse Assistant (CNA) 1 performed hand hygiene between contacts with Resident 2 and Resident 79. 2. Ensure that CNA 1 and Registered Nurse (RN) 1 followed Resident 2 and Resident 54's Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms) to prevent spread of infections. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a call light system (a communication device attached to the bed or on the wall that allows residents to call for assistance from staff when needed) according to the need of two of six residents (Resident 3 and Resident 59) with limited range of motion (ROM) to upper extremities in accordance with the facility's policy and procedure (P&P) titled, P-NP29 Communication - Call System. These deficient practices had the potential to result in a delay in the provision of assistance for all care needs that could lead to accidents for Resident 3 and Resident 59.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident bedrooms accommodated no more than four residents for eight of 41 rooms (Rooms 2, 19, 23, 26, 39 with five beds in the room, and rooms [ROOM NUMBER] with six beds in the room) in the facility. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room space was at a minimum of 80 square feet (sq.ft.- a unit of measurement) for 18 of 41 resident rooms (room [ROOM NUMBER], 17, 19, 22, 23, 26, 27, 28, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 39). This deficient practice had the potential to negatively affect the quality-of-care delivery and the ability of the nursing care to safely provide care and privacy to the residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) care plan was initiated to indicate Resident 1 ' s current therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) ordered for nothing by mouth (NPO). This deficient practice had the potential for Resident 1 to not receive specific care and services specific to Resident 1 ' s needs in accordance to the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered Care Planning.
Inspectors wroteBased on interview, and record review the facility failed to ensure one of three sampled residents (Residents 1) were free from physical abuse by Certified Nurse Assistant (CNA) 1 by failing to: 1. Protect Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1 ' s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility ' s Infection Preventionist (IP) Nurse witnessing CNA 1 was rough during Resident 1 ' s peri care and complained of vaginal pain on 3/14/2025. 2. Protect Resident 1 from further abuse by CNA 1 when IP Nurse and Licensed Vocational Nurse (LVN) 1 allowed CNA 1 to continue caring for Resident 1 on 3/14/2025 and the next day, 3/15/2025. [...]
Inspectors wroteBased on interview, and record review the facility failed notify CDPH, the Ombudsman, and Law Enforcement within two (2) hours of an allegation of abuse. The allegation of abuse was reported to CDPH via fax on 3/15/2025 at 8:06 PM (around 33 hours later), iin accordance with the facility's policy and procedure titled Abuse - Reporting & Investigations. The facility failed to: 1. Notify the allegation of physical abuse by Certified Nurse Assistant (CNA) 1 for Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1 ' s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility ' s Infection Preventionist (IP) Nurse around 11:00 AM witnessing CNA 1 was rough during Resident 1 ' s peri care and complained of vaginal pain on 3/14/2025. [...]
Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement the facility's policy and procedure to prevent, protect, report timely and thoroughly investigate the any allegation of abuse for one or the three sampled residents (Resident 1) who reported to the facility on 3/7/2025 that a certified nursing assistant who provided care to him during ADL (activities of daily living) was rough but dismissed his request even after he requested from the staff to be gentle due to his severe contractures (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part that result in pain) of the arms and legs. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate discharge planning and assistance for resident ' s safe discharge for one of three residents (Resident 1) by not ensuring home health services (medical services being provided at home) and durable medical equipment (DME-reusable medical devices, equipment, or supplies prescribed by a healthcare provider to assist with the treatment, monitoring, or management of a medical condition or disability) is arranged and confirmed for delivery prior to Resident 1 ' s discharge from the facility. This deficiency resulted in Resident 1 did not receive rehabilitation therapy and the durable medical equipment needed for use at home.
Inspectors wroteBased on interview, and record review, the facility failed provide evidence that the Annual Certified Nurse Assistant (CNA) Core Clinical Competencies (ACCC, an assessment and training on the CNAs for the ability to perform clinical nursing care) was completed. In addition, the facility failed to provide evidence that there was a system in place to keep track of the CNA's performance evaluation to ensure eight of eight sampled CNAs (CNA 5, 6, 7, 8, 10, 12, 13, 14) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. [...]
Inspectors wroteBased on interview, and record review the facility failed to: 1. Ensure to provide the name of medications and their indication (reason for the use of the medication) prior to administration of the medications, affecting one (1) of seven (7) residents observed for medication administration (Resident 23.) 2. Account for six (6) doses of Controlled Substances ([CS]- also known as narcotics are medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 13, 45, 57 and 67, in one of two inspected Medication Carts (Station North). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two (2) medication errors out of twenty-four (24) total opportunities contributed to an overall medication error rate of 5.71% affecting two (2) of seven (7) residents observed for medication administration (Resident 20 and 103.) The medication errors were as follows: Resident 20 received a form of calcium (a medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 20's physician. Resident 103 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements, including magnesium) that was different than the one ordered by Resident 103's physician. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to remove and discard from facility stock unused and expired medications, in accordance with the manufacturer ' s requirements in one of two inspected Medication Rooms (Medication Room Station 1 South West). The medications included the following: 1. One Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial, and 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three kitchen staff, Dishwasher (DW) 1 was routinely trained and evaluated for competency related to their duties when: Dishwasher 1 (DW 1) did not know the proper sanitizer test strip to use for the quaternary ammonium (QUAT-a quaternary ammonium-QUAT, a type of sanitizing solution used to sanitize food contact surfaces) sanitizer. DW 1 did not know the procedure for testing strength of the quaternary ammonium sanitizer. This Deficient practice had the potential to result in unsafe and unsanitary food production and can affect residents who were served food from the facility kitchen.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the portion sizes for lunch menu was followed on 7/9/2024 when the facility failed to follow the lunch menu and portion sizes as written for residents on Pureed diet and Mechanical soft diet. During the facility ' s observed Tray Line Service, 12 residents on pureed diet received 4 ounces (oz) of chicken oregano instead of 5 and 1/3 oz. 46 residents on mechanical soft diet received 2 and 2/3 ounces of zucchini instead of 4 oz per the food portion and serving guide. These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss in residents who received food from the kitchen.
Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 16 and 80) when: 1. Certified Nursing Assistant (CNA) 1 was observed standing over Resident 16, who was in bed, while feeding resident for breakfast. 2. CNA 3 was observed standing over Resident 80, who was in bed, while feeding resident for breakfast. This deficient practice violated the resident's rights to maintain and enhanced their self-esteem, self-worth, and the right to be treated with dignity and respect.
Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two out of three sampled residents (Resident 357 and Resident 26) as indicated in the facility's policy and procedure. These deficient practices had the potential not to meet the residents' needs, preferences, especially during emergency.
Inspectors wroteBased on observation, interview, and record review, the facility failed to report a significant change in condition to the attending physician (Physician 1) and responsible party for one of three sampled residents (Resident 48), with a redness on both eyes. This failure resulted in a delay in receiving necessary care and treatment to both eyes which could potentially result in worsened eyes condition and/or infection that could lead to blindness.
Inspectors wroteBased on observation, interview, and record review, the facility failed to preserve one of twenty-seven sampled residents (Resident 36), dignity when failing to pull the privacy curtain while a certified nurse assistant was cleaning the resident without clothes inside the resident ' s room. This failure resulted in Resident 36's privacy violated and had the potential to impact the resident's self esteem and feel humiliated on 7/9/2024.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan that address the necessary interventions in management and services for two out of 22 total sample residents (Resident 48 and Resident 99), when: 1. Resident 48 was observed with redness of both eyes on 7/9/2024. 2. Resident 99 did not have a care plan for the clinical management of inguinal hernia (condition in which soft tissue bulges through a weak point in the abdominal muscles, causing discomfort and/or pain). These failures had a potential to result in inadequate and incomplete provision of care and result in the residents' decline in wellbeing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a resident-centered care plan for one of three sampled residents (Resident 93) to address interventions for occasional bladder incontinence (no control urination) after the removal of the urinary catheter (a flexible tube catheter inserted into the bladder to drain urine from the bladder). As a result of this deficient practice Resident 93 did not receive consitent care and services to regain continence (control) of bladder and prevent urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra).
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care and services to prevent the development of skin breakdown and/or pressure ulcer (painful wound caused as a result of pressure or friction) for one (1) of three sampled Residents (Resident 15) in accordance with the facility's policy and procedure by failing to ensure the Low Air Loss mattress (LAL, mattress designed to circulate a constant flow of air for the management of pressure ulcer) was based on the resident ' s weight as ordered by the physician. The physician ordered for Resident 15's LAL mattress to be set at #6 (setting for 275 pounds [lbs. unit of mass] body weight), the LAL mattress was observed set at #2 (setting for 150 lbs. body weight) and the mattress was soft. This deficient practice had the potential for the resident to be at risk of developing new pressure ulcer.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 63) who had an indwelling catheter (a flexible tube [a catheter] inserted into the bladder that remains (dwells) there for continuous urinary drainage) was provided with care and services to prevent and urinary tract infection (UTI, an infection of the kidney, ureter, bladder, or urethra) by ensuring the urinary indwelling catheter was secured/ anchored and not touching the floor. This deficient practice placed the resident at risk to have potential accidental dislodgement (removal) of the catheter that may result with a trauma to the urethra (a hollow tube that lets urine leave the body) and urinary tract infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for two (2) of three (3) sampled residents (Resident 31 and Resident 50) in accordance with the facility's policy and procedure by failing to: 1. Ensure Resident 31 who was using the nasal cannula (a device that delivers extra oxygen through a tube and into your nose) for continuous oxygen therapy was properly placed on her nostrils (two openings in the nose through which air moves when you breathe) and not on the resident's right cheek. This deficient practice had the potential for Resident 31's lung, heart, brain at risk for hypoxemia (low concentration of oxygen in the blood) and can be life-threatening. 2. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-seven sampled residents (Resident 65), who was observed with pain on 7/9/2024 was assessed for pain and reassessed for effectiveness of pain management and relief interventions as indicated in the facility ' s policy and procedure for pain management. This failure resulted Resident 65 in recieving delayed care and services to relieve pain, which can also potentially affect the resident's ability to maintain the highest practicable level of well-being and healing process.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the need for medically related social services for one out of 3 sampled residents (Resident 99) and ensure that these services are provided. For Resident 99, the facility failed to follow up on Resident 99's plan for surgery for the diagnosis of inguinal hernia (a condition in which soft tissue bulges through a weak point in the abdominal muscles, causing discomfort and/or pain). This deficient practice had the potential for Resident 99 to suffer complications of inguinal hernia such as abdominal pain and discomfort.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility ' s infection control program to prevent the spread and infections in the facility by failing to: 1. Ensure the shared restroom for Room A had labeled urinal and three rectangle wash basins left on top of the reservoir tank (reserve and hold the correct amount of water require to flush the toilet bowl) of the toilet. 2. Ensure Resident 12 ' s urinal at his bedside table with urine was labeled with the resident ' s name and date on when the urinal was first used. 3. Ensure Resident 20 ' s urinal was observed at his bedside table with urine was labeled with the resident ' s name and date on when the urinal was first used. 4. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light for one of six sampled residents (Resident 357). This deficient practice had the potential to result in the residents not to receive necessary immediate care specially during emergency or delay receiving care to meet the residents needs for toileting, personal hygiene and activities of daily living.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's staffing information was posted in a prominent place readily accessible to residents and visitors on a daily basis for one of three nursing station, residents As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident bedrooms accommodate no more than four residents for eight of 41 rooms (Rooms 2, 19, 23, 26, and 39 with five beds in the room, and rooms [ROOM NUMBER] with six beds in the room) in the facility. This deficient practice had the potential to negatively affect the resident ' s privacy and the quality of care and safety of the residents due to inadequate space for nursing care and emergency services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident care area in multiple resident bedrooms were 80 square feet (sq/ft) per resident as required for 18 of 41 resident rooms. This deficient practice had the potential to negatively affect the quality-of-care delivery and the ability of the nursing care to safely provide care and privacy to the residents.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treat 2 out of 5 sampled residents (Resident 2 and Resident 3) with respect and dignity, by not honoring their preferences, and choices regarding activities of daily living (ADL: bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) These deficient practices had the potential to negatively impact residents leading to decreased self- worth, fear of not having control over choices and preferences, and even depression.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a button the patient pushes at the bedside that notifies the nursing staff to request assistance) within reach for 1 out of 5 sampled residents (Resident 4). This deficient practice has the potential to delay necessary assistance, not meeting the needs of the resident promptly. Ensuring that the call light is always within reach is crucial for the safety and well - being of resident.
Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) with diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar [glucose] levels because the body does not produce or use insulin [a type of hormone] normally and required blood sugar monitoring and/or medications to lower blood sugar levels) by failing to ensure to: 1. All appropriate discharge orders for diabetes management from the General Acute Care Hospital (GACH 1) were verified with the attending physician/Medical Doctor (MD) 1 upon admission to the skilled nursing facility on [DATE]. 2. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the physician visits included an evaluation of the resident's condition and total program of care and the appropriateness of the resident's current medication regimen for one of three sampled residents (Resident 1) with a diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has sustained high blood sugar levels) with high blood sugar levels while in the General Acute Care Hospital (GACH) had no physician order for blood sugar monitoring. As a result of this deficient practice, Resident 1 blood sugar was not monitored for high blood sugar and not evaluated for the need for administration of insulin from 4/12- 4/19 (a total of 6 days at the facility). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for a resident ' s needs and preferences for one of three sampled residents (Resident 1), who was by not: 1. Ensuring Resident 1 ' s overhead light cord was within the resident reach. 2. Ensure Resident 1 ' s bed was properly positioned inside the resident ' s room, which resulted in the doorway being obstructed by the foot of the bed and prevents the resident ' s door to fully close. This deficient practice prevented resident 1 from having the ability to turn the light on or off as needed, have adequate lighting, and personal privacy according to the resident ' s preference.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receives mails including packages delivered for one of three sampled residents (Resident 1) through the facility. This deficient practice resulted in the violation of Resident 1's rights to receive mails/packages delivered through the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living receives the necessary services to maintain the resident ' s functional abilities for one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 was provided with a water pitcher at all times, in accordance to the routine distribution of water pitcher to all the residents in the facility. 2. Ensure Resident 1 was provided with the necessary incontinence care as indicated in Resident ' s 1 care plan to check at least every 2 hours for incontinence to ensure soiled and wet areas wre washed, rinsed, and dry. These deficient practices had the potential for Resident 1 to develop skin breakdown, dehydration and urinary tract infection.
Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) on pressure injury (wound caused when an area of skin is placed under pressure) prevention for one of six sampled residents (Resident 4). This deficient practice had the potential to result in Resident 4 developing a pressure injury.
Inspectors wroteBased on interview, and record review, the facility failed to administer antianxiety medication as orderedby the physician for one of two sampled residents. This deficient practice had the potential to negatively affect the resident ' s physical and psychosocial well-being.
Inspectors wroteBased on interview and record review, the facility failed to implement fall (to move in a downward direction) interventions for one (1) of four (4) sampled residents (Resident 1) who was identified as high risk for falls. 1. The facility did not place Resident 1 close to the nurse ' s station after the resident sustained a fall on 2/7/2024. 2. The facility did not follow Resident 1's fall care plan titled Falling Star Program approaches to have R1 within line of sight. These deficient practices resulted in Resident 1 sustaining an injury above the left eyebrow with swelling after falling on 2/7/2024.
Inspectors wroteBased on interview and record review the facility failed to develop a fall risk care plan for one of three sampled residents (Resident 1) who was identified as at risk for falls, in accordance with Resident 1 ' s Fall Risk Evaluation completed on 3/7/2023. This deficient practice resulted in Resident 1 sustaining a fall on 11/16/23 and a repeated fall on 11/17/23 resulting in a hematoma (injury to the wall of a blood vessel, prompting blood to seep out of the blood vessel into the surrounding tissues) to the forehead and swelling around the right and left orbital (the bony cavity that contains the eyeball) eye sockets.
Inspectors wroteBased on observation, interview and record review the facility failed to follow menu consistency guidelines for residents on mechanical soft diet (foods that are physically soft for people who have trouble chewing and swallowing). For the lunch menu the bread crust was not removed prior to the preparation of the mechanical soft plates. This deficient practice had the potential for the residents to choke while eating their food.
Inspectors wroteBased on observation, interview, and record review, the facility failed to enhance a Resident's dignity and respect by failing to provide hygiene timely for one of three sampled residents (Resident 15). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of 19 sample selected residents (Resident 75 ). For Resident 75, the room drapes had yellowish/brownish dry stains on it, windowsills had dust and windows had dry water stains as well as dust. This facility failure had a potential to compromise the health and safety of the residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR; responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting and/or Specialized services) Level II evaluation for one of three sampled residents (Resident 78). This deficient practice had the potential for Resident 78 to not receive necessary care services related to mental disorder.
Inspectors wroteBased on interview and record review, facility failed to develop a person-centered care plan for two of three sampled residents (Resident 411 and Resident 60) in accordance to the facility's policy and procedures by: 1. No baseline care plan developed for Resident 411's diagnosis for depression (mental health condition that involves a low mood and a low interest in activities) and psychotropic medications (drug that affects brain activities associated with mental processes and behavior) 2. No baseline care plan developed for Resident 60's anticoagulant (help prevent blood clots) medications within 48 hours of admission. This deficient practice of not identifying individualized goals had the potential to negatively affect Resident 411 and 60's ability to achieve their highest practicable physical, mental and psychosocial well-being and their continuity of care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a specific and individualized care plan for one out of four sampled residents (Resident 12) by failing to initiate a care plan for Resident 12's use of oxygen therapy (treatment that delivers oxygen for you to breathe). This deficient practice had the potential to result in lack of or delay in delivery of oxygen therapy for Resident 12 which can lead to serious harm, injury or death.
Inspectors wroteBased on observations, interviews and records reviews, the facility failed to revise, reassess and update care plans (a formal process that correctly identifies existing needs and recognizes potential needs or risks) for five of five sampled Residents (Resident 36, Resident 91, Resident 19, Resident 69, and Resident 23): 1. Resident 36's Care Plan did not indicate a revised diet plan for oral meals intake 2. Resident 91's Care Plan did not indicate the location of the dialysis port (a catheter used for exchanging blood to and from a hemodialysis machine and a patient) after the previous dialysis access port was removed. Resident 91's Care Plan did not indicate a revision of Resident 91's scheduled dialysis days. 3. Resident 19's care plan was not updated to reflect current care as the resident is no longer in insulin 4. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for two of two sampled residents (Resident 69 and Resident 36) received appropriate care and services, according to current standards of practice in accordance to plan of care and facility's policy and procedure when: practice when: 1. Resident 69's active restorative nursing program (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve the highest level of well-being possible) order was not being followed as ordered by resident's primary physician. 2. Resident 36's Medication Administration Record (MAR) for 3/2022, indicated that G-tube bolus feeding was provided three times a day (8 AM, 12 PM, and 5 PM). However, licensed staff interviews indicated Resident 36 had not received G-tube feeding for approximately two to three months now. 3. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure ulcers (PU [also known as pressure sores or bedsores] are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) was continuously monitored for one of two sampled residents (Resident 42) who was at risk in developing pressure ulcers This deficient practice had the potential to result in a new onset or deterioration of Resident 42's pressure ulcers.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 36) with gastrostomy tube ([G-tube] tube inserted through the belly that brings nutrition directly to the stomach) feeding was: 1. Reassessed for the medical necessity of the continued use of G-tube via bolus feeding (type of feeding where a syringe is used to administer formula through the feeding tube) after Resident 36's oral intake had increased since 2/7/22 to regular small portion diet, pureed texture, regular thin consistency. 2. Checked for G-tube placement and ensure the head of bed was positioned above 30 degrees prior to administering G-tube bolus feeding, as indicated in the care plan and facility's policy. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care and treatment consistent with professional standards of practice for two of three sampled residents (Residents 3 and 6) who required oxygen administration by failing to ensure facility staff monitored Resident 6's oxygen saturation (refers to the amount of oxygen in the bloodstream) consistently to titrate (adjust based on oxygen need) the oxygen flow rate from 2 liters per minute (L/min) to 5 L/min via nasal cannula (NC; a lightweight tubing with prongs placed in the nose) to maintain the resident's oxygen saturation above 92% continuously as ordered by the physician. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to document the monitoring of dialysis site and provide a sack lunch (a lunch carried, to be eaten at a destination) during dialysis services for one of two sampled residents (Resident 91). These deficient practices had the potential to result in occlusion or infection of the dialysis site of Resident 1 and potentially lead to electrolyte imbalance and hypoglycemia.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the administration of a controlled (narcotic) medication was documented in the narcotic count sheet (Individual Narcotic Record) for one of two medication carts inspected. This deficient practice had the potential to affect residents receiving controlled medications that may increase the risk for drug diversion, misuse, and had the potential for residents to not receive the dosage amount of controlled medication as ordered by the physician.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates were not greater than five percent (%), for two of six randomly selected residents (Resident 35 and Resident 70). During observation of the medication pass, there were two errors out of 26 medication observation opportunities, resulting in a 7.4 % medication error rate. These deficient practices had a potential to place residents at risk for receiving less medication than was ordered by the physician and receiving the wrong medications.
Inspectors wroteBased on observation, interview and record review, the facility failed to label evaporated milk with correct used by date in the dry storage for 10 of 10 cans. These failures had the potential to result in food-borne illnesses to the residents who consume the facility's food.
Inspectors wroteBased on interview and record review, the facility failed to document and maintain a monthly tracking surveillance log for residents with signs and symptoms of infection but did not receive antibiotics to help identify patterns, rates and possible outbreaks in the facility and implement the facility's infection control program designed to prevent the development and transmission of disease and infection, This deficient practice had the potential to result in the transmission of disease and infection to all residents and staff in the facility.
Inspectors wroteBased on interview and record review, the facility failed to document a clinical justification for the use of antibiotic for two of three residents (Residents 87 and 91) reviewed for the facility's Antibiotic Stewardship Program. This deficient practice had the potential for the development of antibiotic resistance due to the lack of screening.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident bedrooms accommodate no more than four residents for eight of 41 rooms (Rooms 2, 19, 23, 26, and 39 with five beds in the room, and rooms [ROOM NUMBER], with six beds in the room).
Inspectors wroteBased on observation, interview and record review, the facility failed to meet the required 80 square feet per resident in multiple resident bedrooms for 11 of 41 residents' rooms. This deficient practice had the potential to negatively affect the resident's privacy and adequate space for nursing care and emergency services.
7 fire safety citations on file: 2 on July 3, 2025, 3 on July 12, 2024, 2 on March 24, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| February 20, 2025 | Fine | $32,139 |
| May 10, 2024 | Payment Denial | 6 days from June 8, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.92 | 4.52 | 3.86 |
| Registered nurses | 0.47 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.72 | 4.09 | 3.42 |
| Nurse aides | 2.57 | ||
| Licensed practical nurses | 0.88 | ||
| Nursing staff turnover (share who left in a year) | not reported | 36.7% | 45.8% |
| Registered nurse turnover | not reported | 38.1% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.96 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.01 on weekdays and 3.72 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.09 in April to June 2025 to 3.92 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.92 | 0.47 | 4.01 | 3.72 | 0.0% | 0 of 90 | 122 |
| Jul to Sep 2025 | 4.09 | 0.50 | 4.24 | 3.72 | 0.0% | 0 of 92 | 120 |
| Apr to Jun 2025 | 4.09 | 0.46 | 4.20 | 3.83 | 0.0% | 0 of 91 | 118 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Trains nurse aides: this home runs a state-approved CNA program for its own hires (state list: CDPH Facility Based Nurse Assistant Training Programs, as of February 13, 2026). A nursing home cannot charge aides it employs, or has offered a job, for state-approved training (42 CFR 483.152(c)). See Montrose Springs Skilled Nursing & Wellness Center CNA training on CareerFunded, our sister site for career training.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 8.0 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.1 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.0 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.7 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 3.7 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.1 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 22.1 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 9.1 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 2.3 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.8 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Montrose Springs Skilled Nursing & Wellness Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
54.7% this home
No different from the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 64 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 172 eligible stays.
7.1% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 114 eligible stays.
37.8% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 74 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 113 residents counted.
2.7% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 113 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 9 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE, LLC. CMS links this home to Pacific Healthcare Holdings, a group of 15 nursing homes averaging 1.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Pacific Healthcare Holdings, Inc. | 5% or greater direct ownership interest | Organization | 88% | 08/31/2007 |
| Rechnitz, Shlomo | Corporate officer | Individual | 08/31/2007 | |
| Corporate Interface Services LLC | Operational/managerial control | Organization | 03/18/2024 | |
| Rockport Administrative Services, LLC | Operational/managerial control | Organization | 01/15/2008 | |
| Aghajanyan, Ani | Operational/managerial control | Individual | 06/12/2017 | |
| Karakashian, Garo | Operational/managerial control | Individual | 02/01/2017 | |
| Rechnitz, Shlomo | Operational/managerial control | Individual | 08/31/2007 | |
| Corporate Interface Services LLC | Adp of the SNF | Organization | 04/10/2025 | |
| Rockport Administrative Services, LLC | Adp of the SNF | Organization | 04/10/2025 | |
| Aghajanyan, Ani | Adp of the SNF | Individual | 06/12/2017 | |
| Karakashian, Garo | Adp of the SNF | Individual | 02/01/2017 | |
| Rechnitz, Shlomo | Adp of the SNF | Individual | 08/31/2007 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.