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.

The visit was complaint-related, triggered by concerns about inadequate nail care for resident #104, insufficient staffing affecting residents #59 and #162, and improper medication administration for resident #288. The report includes substantiated findings for all these complaints.

The facility failed to provide proper nail care for one resident, had inadequate staffing levels on weekends affecting multiple residents, and administered pain medication outside of physician-ordered parameters for one resident, potentially causing medication errors.

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.

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 who reported that dietary preferences were not honored and poor communication by staff, and resident #27 who was not wearing the prescribed C-collar as ordered. Interviews with staff revealed lack of documentation and unclear adherence to orders. The complaint was substantiated with findings of deficient practices.

The facility failed to honor the dietary preferences of resident #287, resulting in a lack of resident autonomy, and failed to ensure that resident #27 wore a prescribed C-collar as ordered by the physician, 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 notification documentation, inaccurate Minimum Data Set (MDS) assessments, inadequate pressure ulcer care, failure to obtain ordered resident weights, improper care and flushing of feeding tubes, failure to maintain accurate medical records including advance directives, failure to follow infection control protocols during perineal/catheter care, and food safety violations related to hair restraints and food storage.