Montecito Post Acute Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Montecito Post Acute Care and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689May 20, 2025

  Based on record review, observations of practice, staff and representative interviews the facility failed to ensure adequate supervision for 1 of 2 sampled residents (#39) while smoking. The deficient practice resulted in the resident sustaining life-threatening injuries. Findings include: Resident #39 was admitted originally on March 3, 2014 and readmitted on [DATE] with diagnoses that include hemiplegia and hemiparesis, peripheral vascular disease, dementia, long QT syndrome, cognitive communication disorder, anemia and major depressive disorder. […]

• No harm, potential for more than minimal, patternF725Feb 14, 2025

  Based on clinical record review, staff interviews, and policy review, the facility failed to ensure adequate staffing was provided on weekends to meet the needs of multiple residents (#59, and #162). The deficient practice could result in residents' care needs not being met. Findings Include: -Regarding Resident #59 Resident #59 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure and quadriplegia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. […]

• No harm, potential for more than minimal, patternF842Nov 22, 2023

  Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure accurate documentation of showers/baths in the clinical record for two residents (#190 and #193). The deficient practice could result in an inaccurate documentation resulting in the potential of needed cares not being provided. Findings include: -Resident #193 was admitted on [DATE] with diagnoses of that included displaced fracture of the first cervical vertebra, repeated falls, and acute urinary tract infection without hematuria. The shower sheets record revealed the resident received a bath or shower on March 3,7,10, 14, 17, 18, 21, 24, 28 and 31, 2022. These shower sheets were signed by the CNA and the nurse. […]

• No harm, potential for more than minimal, patternF686Jul 1, 2022

  Based on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#162) received the necessary care to prevent and to promote the healing of pressure ulcers. The sample size was 3 residents. The deficient practice could result in formation or worsening of pressure ulcers. Findings include: Resident #162 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on August 23, 2021 revealed an ADL (activities of daily living) self-care performance deficit care plan with interventions that included restorative nursing assistant (RNA) to don/doff bilateral PRAFO (pressure relief ankle foot orthosis) x 6 hours as tolerated and out of bed in Geri-chair as tolerated by… […]

• No harm, potential for more than minimal, patternF812Jul 1, 2022

  Based on observations, staff interviews, and policy reviews, the facility failed to ensure staff members wore hair restraints and food items were stored in accordance with professional standards for food service safety. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding hair restraints During the initial kitchen observation conducted on June 27, 2022 at 8:30 a.m., a staff member who had a long, bushy beard, approximately 4 inches in length was observed with his beard unrestrained while putting away supplies around the kitchen. Another observation of the kitchen was conducted on June 29, 2022 at 10:05 a.m. […]