Inspection Reports for
Montecito Post Acute and Care

The complaint investigation found that two residents (#22 and #19) eloped from the facility. Resident #22 was missing on August 17, 2025, and found wandering outside, requiring emergency room care. Resident #19 was missing overnight on August 17-18, 2025, with personal belongings missing, and returned the next day. Both elopements were deemed isolated incidents. The facility's door alarm was not active during some hours, and monitoring was insufficient.

The facility failed to ensure adequate supervision and monitoring to prevent elopement for two residents, resulting in both residents leaving the facility unsupervised. The incidents were deemed isolated, but the facility's door alarm system and monitoring were found insufficient during certain hours.

The complaint investigation found that the resident was smoking unsupervised on a non-designated patio, which led to his blanket catching fire and sustaining third-degree burns. The resident's family was notified and the resident was sent to a burn center. The facility's smoking policy and supervision procedures were reviewed and found to have been inadequately followed.

The facility failed to ensure adequate supervision for one resident (#39) while smoking, leading to the resident suffering third-degree burns after his blanket caught fire. Interviews with staff and review of policies revealed lapses in supervision and control of smoking materials.

Investigation conducted for multiple intakes. Two deficiencies cited related to laboratory services and medical director responsibilities.

The facility was found deficient in providing proper nail care for a resident, ensuring adequate staffing on weekends, and following physician orders for pain medication administration. Deficiencies were noted in resident grooming, staffing levels, and medication administration practices, all posing minimal harm or potential for actual harm.

Recertification and complaint survey conducted with multiple complaint investigations. Four deficiencies cited related to administrator and director of nursing responsibilities.

Recertification survey for Medicare under Life Safety Code 2012. Facility meets standards based on acceptance of plan of correction. One deficiency cited related to corridor doors.

The complaint investigation revealed issues with unnecessary antibiotic use for resident #193 and inaccurate documentation of bathing/shower care for residents #190 and #193.

The facility failed to ensure one resident was free from unnecessary antibiotic medication due to lack of adequate indication, and failed to ensure accurate documentation of showers/baths for two residents, potentially resulting in needed care not being provided.

The complaint investigation focused on two residents: resident #287 regarding failure to honor dietary preferences, and resident #27 regarding failure to ensure treatment with a C-collar as ordered. The complaints were substantiated with findings of deficient practices.

The facility failed to honor the dietary preferences of resident #287, resulting in a lack of documented preferences and poor communication with staff. Additionally, the facility failed to ensure resident #27 wore a prescribed C-collar as ordered, with no documentation of refusals or physician notification.

The facility was found deficient in multiple areas including failure to honor resident self-determination, incomplete bed hold notifications, inaccurate Minimum Data Set (MDS) assessments, inadequate pressure ulcer care, failure to obtain ordered resident weights, improper care and maintenance of feeding tubes, failure to maintain accurate medical records including advance directives, incomplete bed hold documentation, and lapses in infection prevention and control practices.