California ›Montrose

Montrose Springs Skilled Nursing & Wellness Center

2635 Honolulu Ave, Montrose, CA 91020 · Los Angeles County · 109 certified beds · avg 122 residents/day · certified since Dec 23, 1974

Part of chain: PACIFIC HEALTHCARE HOLDINGS (15 facilities, chain avg rating 1.9★)

2/5
Health inspection rating (on-site)
3
Serious findings on record
$32,139
Fines, last 3 years
3.80
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Mar 28, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 5, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 12, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 9, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 10, 2024 · F-0635 · triggered by a complaint

The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted.

Why it matters: Without admission orders, a new resident may miss critical medications or treatments during their first days.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 3, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (82)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jul 1, 2026D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Jul 1, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 1, 2026D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Apr 20, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 7, 2026D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 26, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Feb 26, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Feb 26, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 22, 2026D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 22, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jul 3, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 3, 2025D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 3, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jul 3, 2025D · Potential for harm, one-offThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Jul 3, 2025D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jul 3, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 3, 2025D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jul 3, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 3, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jul 3, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jul 3, 2025D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Jul 3, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 3, 2025D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Jul 3, 2025B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Jul 3, 2025B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
May 1, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 28, 2025▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Mar 28, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 12, 2025▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 20, 2025D · Potential for harm, one-offThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint
Jul 12, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required.
Jul 12, 2024E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jul 12, 2024E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jul 12, 2024E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 12, 2024E · Potential for harm, repeatedThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
Jul 12, 2024E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Jul 12, 2024D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 12, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 12, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jul 12, 2024D · Potential for harm, one-offThe facility did not keep residents' personal and medical information private and confidential.
Jul 12, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 12, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Jul 12, 2024D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Jul 12, 2024D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 12, 2024D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Jul 12, 2024B · Minimal risk, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Jul 12, 2024B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Jul 12, 2024B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
May 17, 2024D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint
May 17, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
May 10, 2024▲ G · Actual harm, one-offThe facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted. · from a complaint
May 10, 2024D · Potential for harm, one-offThe facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint
Apr 9, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Apr 9, 2024D · Potential for harm, one-offThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint
Apr 9, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Mar 6, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 6, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Feb 27, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 29, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 24, 2022E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Mar 24, 2022D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Mar 24, 2022D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 24, 2022D · Potential for harm, one-offThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Mar 24, 2022D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Mar 24, 2022D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 24, 2022D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 24, 2022D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Mar 24, 2022D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Mar 24, 2022D · Potential for harm, one-offThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Mar 24, 2022D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Mar 24, 2022D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Mar 24, 2022D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 24, 2022D · Potential for harm, one-offThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Mar 24, 2022D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 24, 2022D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Mar 24, 2022D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 24, 2022B · Minimal risk, repeatedThe facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Mar 24, 2022B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (22 → 15).

YearCitationsSerious (G–L)Worst severity that year
2022190E
202310D
2024321G ▲
2025202G ▲
2026100D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $32,139, plus 1 Medicare payment denial period.

DateTypeAmount / length
Feb 20, 2025Fine$32,139
May 10, 2024Payment Denial6 days from Jun 8, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.804.313.95bottom 27% in California; top 49% in the U.S.
Registered Nurse hours0.460.610.69bottom 45% in California; bottom 31% in the U.S.
Weekend total nurse staffing3.603.903.50bottom 39% in California; top 38% in the U.S.
Weekend RN hours (not acuity-adjusted)0.320.510.48bottom 39% in California; bottom 36% in the U.S.
Total nursing staff turnover (%)0.036.745.8—
RN turnover (%)0.038.142.9—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.92, RN 0.47, weekend 3.72. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Pacific Healthcare Holdings, INC.Organization5% or Greater Direct Ownership Interest88%08/31/2007
Aghajanyan, AniIndividualOperational/Managerial ControlNOT APPLICABLE06/12/2017
Aghajanyan, AniIndividualADP of the SNFNOT APPLICABLE06/12/2017
Corporate Interface Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE03/18/2024
Corporate Interface Services LLCOrganizationADP of the SNFNOT APPLICABLE04/10/2025
Karakashian, GaroIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2017
Karakashian, GaroIndividualADP of the SNFNOT APPLICABLE02/01/2017
Rechnitz, ShlomoIndividualCorporate OfficerNOT APPLICABLE08/31/2007
Rechnitz, ShlomoIndividualOperational/Managerial ControlNOT APPLICABLE08/31/2007
Rechnitz, ShlomoIndividualADP of the SNFNOT APPLICABLE08/31/2007
Rockport Administrative Services, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/15/2008
Rockport Administrative Services, LLCOrganizationADP of the SNFNOT APPLICABLE04/10/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
La Crescenta Healthcare Center0.9 miLa Crescenta, CA★★★★★4/5
Montrose Healthcare Center1.2 miMontrose, CA★★★☆☆3/5
Oakpark Healthcare Center2.5 miTujunga, CA★★★★★3/5
Golden Haven Care Center3.6 miGlendale, CA★☆☆☆☆1/5
Dreier's Nursing Care Center3.7 miGlendale, CA★★☆☆☆2/5
Autumn Hills Health Care Center3.9 miGlendale, CA★★★☆☆2/5
Glendale Post Acute Center4.1 miGlendale, CA★☆☆☆☆1/5
Glendale Adventist Medical Center DP/SNF4.2 miGlendale, CA★★★★★5/5
Broadway Manor Care Center4.6 miGlendale, CA★★☆☆☆2/5
Royal Palms Post Acute4.6 miGlendale, CA★★☆☆☆1/5

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Facility data as of CMS processing date 2026-08-01. CCN 056322.