Nursing Care Index

Montrose Springs Skilled Nursing & Wellness Center

Montrose, Los Angeles County, California · CCN 056322 · For-profit (LLC) · part of Pacific Healthcare Holdings (15 facilities, chain average 1.9 stars)

CMS rates Montrose Springs Skilled Nursing & Wellness Center 3 of 5 overall as of August 2026. 109 certified beds, 122 residents a day on average. 82 citations on record from the current inspection cycles, 3 involving actual harm; 1 fine totalling $32,139 and 1 payment denial.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★★★☆☆ 3 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 5 of 5

Staffing

Total nurse staffing3.9247 hours per resident per day
Registered nurses0.47302 hours per resident per day
Weekend total3.72366 hours per resident per day

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-07-01
complaint survey
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has no plan of correction
2026-07-01
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has no plan of correction
2026-07-01
complaint survey
Provide timely, quality laboratory services/tests to meet the needs of residents.
Administration Deficiencies · tag F0770
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has no plan of correction
2026-04-20
complaint survey
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-05-08
2026-04-07
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-04-24
2026-02-26
complaint survey
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-20
2026-02-26
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-20
2026-02-26
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-03-20
2026-01-22
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-14
2026-01-22
complaint survey
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-02-14
2025-07-03 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-07-25
2025-07-03 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies · tag F0552
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Honor the resident's right to organize and participate in resident/family groups in the facility.
Resident Rights Deficiencies · tag F0565
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 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 Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 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 · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 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 · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-07-25
2025-07-03 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 · tag F0911
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2025-07-25
2025-07-03 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies · tag F0912
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2025-07-25
2025-05-01
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-22
2025-03-28
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-04-05
2025-03-28
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-04-05
2025-03-12
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-04-09
2025-02-20
complaint survey
Plan the resident's discharge to meet the resident's goals and needs.
Resident Assessment and Care Planning Deficiencies · tag F0660
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-14
2024-07-12 Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · tag F0730
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Nutrition and Dietary Deficiencies · tag F0802
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 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 · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0697
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies · tag F0919
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-05
2024-07-12 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · tag F0732
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 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 · tag F0911
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-07-12 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies · tag F0912
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2024-08-05
2024-05-17
complaint survey
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies · tag F0557
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-14
2024-05-17
complaint survey
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-14
2024-05-10
complaint survey
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Resident Assessment and Care Planning Deficiencies · tag F0635
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-06-03
2024-05-10
complaint survey
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Nursing and Physician Services Deficiencies · tag F0711
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-03
2024-04-09
complaint survey
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies · tag F0558
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-29
2024-04-09
complaint survey
Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights Deficiencies · tag F0576
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-29
2024-04-09
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-04-29
2024-03-06
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-03-22
2024-03-06
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-03-22
2024-02-27
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-03-20
2023-11-29
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-12-26
2022-03-24 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.
Nutrition and Dietary Deficiencies · tag F0803
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-26
2022-03-24 Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Resident Rights Deficiencies · tag F0557
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 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.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies · tag F0655
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 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.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-26
2022-03-24 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 · tag F0911
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2022-04-26
2022-03-24 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Environmental Deficiencies · tag F0912
B No actual harm, with potential for minimal harm; pattern Deficient, Provider has date of correction
2022-04-26

Fines and payment denials

DatePenaltyAmount
2025-02-20Fine$32,139
2024-05-10Payment denial for 6 days from 2024-06-08

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Pacific Healthcare Holdings, Inc.
Organization
5% or greater direct ownership interest88%2007-08-31
Corporate Interface Services LLC
Organization
adp of the snf2025-04-10
Rockport Administrative Services, LLC
Organization
adp of the snf2025-04-10
Corporate Interface Services LLC
Organization
operational/managerial control2024-03-18
Rockport Administrative Services, LLC
Organization
operational/managerial control2008-01-15
Aghajanyan, Ani
Individual
adp of the snf2017-06-12
Karakashian, Garo
Individual
adp of the snf2017-02-01
Rechnitz, Shlomo
Individual
adp of the snf2007-08-31
Rechnitz, Shlomo
Individual
corporate officer2007-08-31
Aghajanyan, Ani
Individual
operational/managerial control2017-06-12
Karakashian, Garo
Individual
operational/managerial control2017-02-01
Rechnitz, Shlomo
Individual
operational/managerial control2007-08-31

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Los Angeles County.