Montecito Heights Healthcare & Wellness Centre, LP

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices, by failing to:Ensure food in refrigerators and dry storage were labeled and dated. Ensure food beyond expiration dates was discarded. Ensure potentially hazardous foods were not stored above ready-to-eat foods. Ensure milk that was stored within the temperature danger zone (a range of temperatures, 41-135 degrees Fahrenheit [ F], where harmful bacteria can multiply rapidly) was not served to residents. Ensure unlabeled and expired food was not kept in the resident refrigerator. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in all residents who received food from the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to submit the Payroll Based Journal (PBJ - a mandatory reporting system for healthcare facilities to submit direct care staffing information that is collected and can be audited) for the first quarter (every three months) from 10/1/2025 to 12/31/2025 to the Centers of Medicare and Medicaid (CMS, the federal agency that provides health coverage). This failure compromised the accuracy of the facility's staffing levels and had the potential to affect the facility not to be adequately staffed and/or have the necessary staff to provide care to meet the needs of the residents (in general).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices by failing to:1. Ensure nephrostomy tubing (a thin catheter that drains urine from the kidney into a bag) was found on the floor for one of one sampled resident (Resident 25).2. Implement an effective water management program to reduce the risk of Legionella (a [NAME] of bacteria naturally found in fresh water) and other waterborne pathogens by failing to maintain documentation of routine cold-water monitoring for the facility's water distribution system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when the reach-in refrigerator (an upright, standalone, commercial cooling unit designed to keep perishable ingredients cold) in the kitchen had an internal temperature within the temperature danger zone (a range of temperatures, 41-135 degrees Fahrenheit [ F], where harmful bacteria can multiply rapidly). This deficient practice had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 68 of 70 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to ensure informed consent (a form signed by resident after providers fully explain a proposed treatment, its risks, benefits, and alternatives) was signed before ordering psychotropic (also referred to as psychoactive drugs, a medication that affects brain activities associated with mental processes and behavior) and antidepressant drug (medication to treat depression [persistent sadness, low mood, loss of interest]) and there was a stop date on as needed medication for psychotropic drug administration for one of five sampled residents (Resident 87). This failure had potential for Resident 87 unable to know the side effects of psychotropic medication prior to administering medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set {(MDS), a resident assessment tool}, was accurately completed as follows:The facility did not accurately assess anticoagulant use (medications that prevent or slow the blood's ability to clot) for one of three sampled residents (Resident 6). The facility failed to accurately assess and document the type and location of the dialysis access site (an invasive procedure in which blood is filtered through a machine to remove waste and excess fluid as a replacement for kidney function) for one of one sampled residents (Resident 7). This failure had the potential to lead to inaccurate care planning for the dialysis access site and to cause physical and psychosocial harm to Resident 7. This failure had the potential to result in the lack of an appropriate care plan for anticoagulant therapy for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and accurate medication management practices for two of four sampled residents (Resident 42 and Resident 71) by failing to:-Ensure accurate medication administration documentation of the lidocaine patch (topical analgesics that provide temporary, localized pain relief by numbing nerve signals in the treated area) for Resident 42.- Ensure narcotic accountability record (count sheet) matched the electronic medication administration record (eMAR), for Resident 71. These failures had the potential for medication error, misuse, and/or drug diversion (involving the transfer of a legally-prescribed controlled substance from the individual for whom it was prescribed to another person).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 24 of 68 residents (unidentified) with a Carbohydrate-Controlled (CCHO) diet order (a therapeutic diet intended to limit or balance the amount of carbohydrates consumed) when kitchen staff (Cook 1) provided twice the amount of potatoes as indicated This failure had the potential to negatively affect 24 of 68 residents' (unidentified) nutritional status by altering the intended carbohydrate content of the meal, which may impact nutrient balance, blood sugar control, and overall therapeutic effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu when kitchen staff used a cornstarch slurry (a mixture of cornstarch and a liquid used to thicken soups, gravies, and stir-fry sauces) instead of gravy as indicated in the recipe for 5 of 68 meal trays requiring gravy. This failure had the potential to alter nutrition and increase meal dissatisfaction for 5 of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI: standardized framework (0-7 levels) that uses consistent terminology, colors, and testing methods to define texture-modified foods and thickened liquids for people with swallowing difficulties [dysphagia]), Level Five minced and moist foods - (All foods prepared for this diet must be soft, moist with all excess fluid drained, and minced to size no larger than 4mm fits through the gaps of fork prongs) meal requiring level five minced and moist foods. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain residents' quality of life by not conducting and documenting a change of condition (COC) assessment for two of two sampled residents (Residents 90 and 89) who were roommates and experiencing an interpersonal conflict. This deficient practice had the potential to cause emotional distress and affect the residents' self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to assess, plan and coordinate care) meeting for Resident 25 about noncompliance with keeping her nephrostomy tube (a thin catheter that drains urine from the kidney into a bag) off the floor was conducted for one out of one sampled resident. This failure had the potential for Resident 25's Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a dementia (a progressive state of decline in mental abilities) care plan (a personalized document outlining a person's health conditions, care services, and treatment goals) within 48 hours of admission for one of the five sampled residents (Resident 87). This failure had potential to cause delay in care or nursing services for Resident 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate an anticoagulant (blood thinner- a medication or substance that prevents or slows down the clotting of blood) care plan for one of one sampled resident (Resident 82). This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received. During a review of Resident 82's admission Record (AR), the AR indicated the facility admitted the resident on 6/15/2026, with diagnoses including chronic obstructive pulmonary disease (a group of long term lung diseases that cause damaged airways and trapped air, making it difficult to breathe), pneumonia (an infection of the lungs that causes the tiny air sacs to become inflamed and fill with fluid), and sepsis (infection-fighting processes turn on the body, causing the organs to work poorly). [...]

Inspectors wroteBased on interview and record review the facility failed to update and revise the care plan (a plan of care that summarizes a resident's health conditions, current treatments, and specific care and services facility staff [in general] need to provide a resident to promote healing and prevent a worsening of a condition) for Trazadone (a type of medication used to treat depression, a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities) for one out of five sampled residents (Resident 11). This failure had potential for Resident 11 to receive care that was not in alignment with the resident's physician orders and needs.

Inspectors wroteBased on interview and record review, the facility failed to document a follow-up assessment after a change of condition (COC- a significant alteration in a resident's health status requiring physician notification) for one out of one sample resident (Resident 83). This failure had the potential for Resident 83 to continue experiencing nausea without appropriate monitoring and interventions. During a review of Resident 83's admission Record, the admission Record indicated that Resident 83 was admitted on [DATE] with a diagnosis of acute respiratory failure with hypoxia (a condition where the lungs cannot supply enough oxygen to the bloodstream), pneumonia (an infection/inflammation in the lungs), and immunodeficiency (when the immune system's ability to fight off infectious diseases is weakened). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monthly weights was being done and recorded to monitor and assess nutrition and hydration during continued poor meal intake (an ongoing, prolonged inability to consume enough food or beverages to meet the body's physiological energy and nutritional needs) for one of one sampled resident (Resident 17). This deficient practice had the potential to result in inadequate nutritional intake, continued weight loss, dehydration, worsening malnutrition, and functional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) reviewed for respiratory care, received the necessary respiratory care and services by failing to: -Ensure Resident 1's oxygen nasal cannula (a simple, lightweight plastic tube used to give a person extra oxygen) did not rest on the floor while Resident 1 used the oxygen nasal cannula on 6/22/2026 at 10:29 AM This failure had the potential for Resident 1 to experience an increased risk for respiratory infections (illnesses that affect the parts of your body involved in breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 33) reviewed for hemodialysis (HD, treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received care and services consistent with professional standards of practice by failing to: 1. Ensure Resident 1's weight was accurately assessed and documented after dialysis on 6/17/2026. 2. Ensure Resident 33's permcath dialysis catheter (a soft, flexible plastic tube inserted into a large vein, usually in the neck) was accurately assessed and documented on 6/17/2026, 6/22/2026, and 6/23/2026. These failures had the potential for inaccurate information to have been used to calculate Resident 33's dialysis, leading to improper dialysis care treatment orders, infection, serious injury and/or harm.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Valproic Acid (a medication that is used to stabilize mood) level as recommended by the facility's consultant pharmacist (a healthcare professional who provides specialized expertise to healthcare facilities, typically focusing on ensuring the safe and effective use of medications) during the Monthly Medication Regimen Review (MRR, when a consultant pharmacist reviews and analyzes a resident's medication list, ensuring that the medications are appropriate, effective, and safe) for one of five sampled residents (Resident 61). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food preferences were honored for three of three sampled residents (Resident 50, Resident 86 and Resident 67) when: a. Resident 86's likes and dislikes was not reflected on the meal tray ticket. b. Resident 50's tray ticket was not updated reflecting food texture preferences and request for soups for three meals. c. Resident 67's did not provide food preference accommodation. These failures had potential to cause decreased food intake, weight loss, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to document infection prevent education to one out of one sampled resident (Resident 25) in a consistent and timely manner. This failure of incomplete and missing documentation had the potential for Resident 25 to not receive necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure to assess two of two sampled residents (Resident 7 and Resident 63) for pain levels by failing to: 1. Ensure licensed nurses (in general) followed Resident 7's physician orders to assess/monitor Resident 7's pain levels and document prior to administering hydromorphone (a strong medication used for moderate to severe pain, especially when other pain relievers haven't worked). 2. Ensure to reevaluate the pain level for Resident 63 within an hour after the administration of a pain relief medication as indicated in the facility's Pain Management policy and procedure. These failures had the potential for Resident 7 and Resident 63's pain not to be treated effectively and had the potential for Resident 7 to receive too much pain relief medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure boxed food items were not stored directly on the floor. 2. Ensure the dispensing scoop was not stored inside the salt container These failures placed the residents of the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC, a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending) to one of three sampled residents (Resident 129). This failure had the potential to result for Resident 129 not to be informed of her coverage end date and not being able to exercise her right to file an appeal of her discharge from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately performed for two of six sampled residents (Resident 67 and Resident 48) by failing to: 1. Ensure the MDS assessment for restraints (any physical, chemical, or mechanical device or method used to limit a patient's movement or restrict their freedom of movement, typically to prevent harm to themselves or others) was accurately performed for Resident 67. 2. Ensure the MDS assessment for bowel and bladder was accurately documented for Resident 48. This failure had the potential to result in inadequate care for Resident 67 and Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan for one of one sampled resident (Resident 23) by failing to address Resident 23's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) access site. This failure had the potential for Resident 23 not to receive the appropriate care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for two of six sampled residents (Resident 64 and Resident 38) by failing to: 1. Ensure to create an appropriate care plan for Resident 64's incontinence (the involuntary leakage of bodily fluids, specifically urine or stool). 2. Ensure to create a care plan to address Resident 38's oxygen use. This failures had the potential to result in Resident 64 and Resident 38 not to have their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for one of four sampled residents (Resident 36) who was at risk for developing pressure injuries/sores (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) by failing to: 1. Ensure to provide Resident 36 with bilateral (both) heel protectors (a device used to prevent and treat heel pressure sores) while Resident 36 was in bed. This failure placed Resident 36 at risk for developing PIs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician orders for one of four sampled residents (Residents 36) by failing to provide Resident 36 with bilateral (both) padded siderails (are adjustable metal or rigid plastic bars that attach to the bed) for safety. This failure had the potential to place Resident 36 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 48 and Resident 278) received appropriate urinary and bowel care services by failing to: 1. Ensure Resident 48 who was continent (able to verbalize/control bladder and bowel movements) on admission, received services and assistance to maintain continence. 2. Ensure Resident 278's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) did not have a dependent loop (restricts urine flow from the bladder and can lead to improper bladder emptying), and urine did not backflow to the urine drainage port. These failures had the potential to negatively affect Resident 48 and Resident 278 from receiving the proper care necessary to prevent urinary tract infection (UTI, an infection in any part of the urinary system), and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services for two of four sampled residents (Resident 7 and Resident 10) by failing to: 1. Ensure to label Resident 7's nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils [nose] and the tubing is fitted over the patient's ears) as indicated in the facility's Oxygen Therapy policy and procedure. 2. Ensure to change Resident 10's humidifier bottle (a medical device used to humidify oxygen) when empty. These failures had the potential to place Resident 7 at risk for respiratory infections and for Resident 10 not to receive effective respiratory therapy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 23) who was on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received dialysis care and treatment by failing to: 1. Ensure to assess Resident 23's dialysis access sites (a way to reach the blood for dialysis). 2. Ensure to assess Resident 23 before and after (pre and post) dialysis treatment on 4/7/2025, 4/14/2025, 4/23/2025, and 4/30/2025. These failures had the potential to result in undetected complications of a dialysis access site and could lead to the delay of necessary care for Resident 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to result in inadequate usable living space for the residents and working space for the healthcare staff.

Inspectors wroteBased on interview and record review the facility failed to ensure the assistive signaling devices used to prevent falls were monitored for placement and function for one of two sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Monitor the placement and functioning of the bed alarm when initially applied on12/23/24. 2. Monitor the placement and functioning of the wheelchair alarm when initially applied on 1/3/25. Monitoring for the placement and function for the bed and wheelchair alarms started on 3/18/25. These deficient practices had the potential for the assistive devices to malfunction without the facility's knowledge and had the potential for Resident 1 to leave the bed and/or the wheelchair without the facility's knowledge and may lead to accident.

Inspectors wroteBased on interview and record review the facility failed to administer adequate supplemental oxygen in accordance with professional standards of practice for one of three sampled residents (Resident 1). For Resident 1 who was found on 9/20/24 at 7:40 p.m. with altered level of consciousness (ALOC, state of reduced alertness or inability to arouse) and with oxygen saturation (O2 sat - measurement of how much oxygen the blood is carrying as a percentage) of 64% (normal range is between 95% to 100%), the facility failed to administer oxygen by non-rebreather mask (oxygen mask that delivers high concentration of oxygen) immediately while waiting for the arrival of the paramedics. This deficient practice had the potential for Resident 1 to continue to deteriorate and not receive enough oxygen to sustain life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents and their family member/next of kin were given the opportunity to discuss and review the documents the residents signed for two of two sampled residents (Resident 1 and Resident 2). For Resident 1 and Resident 2, the facility failed to ensure the Assisted Living Waiver (ALW, program that provides specified benefits to eligible residents to remain in their community as an alternative to residing in a licensed health facility) forms and consents signed by Resident 1 and Resident 2 on 7/26/24 were in the language Resident 1 and Resident 2 could understand. These deficient practices resulted in Resident 1, Resident 2 and their families not being aware of what forms and consents Resident 1 and Resident 2 signed.

Inspectors wroteBased on interview and record review the facility failed to provide a Notice of Proposed Transfer and Discharge to one of two sampled residents (Resident 2). For Resident 2, the facility failed to provide the Notice on 8/29/24 when Resident 2 had a planned discharged to a lower level of care on 9/4/24. This deficient practice had the potential for Resident 2 not be given her right to know in writing the date and reasons for her discharge.

Inspectors wroteBased an observation, interview, and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for four of six days for the month of June 2024. As a result, the total number of staff and the actual hours worked was not readily accessible to residents, family, or visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights (an alerting device for nurses to assist a patient when in need) were within the residents' reach for two of 19 sampled residents (Resident 10 and Resident 113). These deficient practices had the potential to result in a delay in care and services and Resident 10 and 113's inability to request assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise care plans for two of 19 sampled residents (Resident 20 and Resident 47 ) investigated for care planning. The facility failed to revise Resident 20's care plan to reflect a discontinuation of antibiotic therapy (medications that are used to treat infection by stopping bacteria from reproducing or destroying them) and failed to revise Resident 47's care plan after discontinuing a urinary indwelling catheter (a tube inserted in the bladder to drain the urine). This deficient practice placed the residents at risk for inconsistent implementation of care plans which may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 20), by not rotating the site for administration of a subcutaneous injection (an insertion of medication beneath the skin) of Basaglar (a long-acting insulin [hormone that lowers the level of sugar in the blood]). The deficient practice had the potential to result in the resident developing a lipodystrophy (a condition when fat either break down or builds up under the skin, causing interference with insulin abortion).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 21) was free of unnecessary medication by failing to follow the Physician's Order to discontinue Enoxaparin (a blood thinner given via injection) 40 milligrams (mg - unit of measurement) subcutaneously (SQ - injected under the skin) dated 5/30/2024. This deficient practice resulted in Resident 21 receiving Enoxaparin from 5/30/2024 to 6/5/2024 without a Physician's Order, which placed the resident at risk for internal bleeding, hemorrhage (loss of blood from damaged blood vessels), organ failure, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a therapeutic diet (specialized diet designed to address specific medical conditions and improve health outcomes) was served per Physician's Order for one of six sampled residents (Resident 114). This deficient practice had the potential to place Resident 114 at risk for choking and aspiration (inhaling small particles of food or drops of liquid into the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dycem (non-slip mat that anchors items to the trays or tables and prevents cups and plates from slipping off trays or tables) to the resident for one of three sampled residents (Resident 39). This deficient practice had the potential to result in the resident being unable to maintain or improve his ability to eat or drink independently.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the indwelling catheter bag (a transparent bag where urine was collected and connected to a tubing that was inserted in the body through the bladder) was not touching the floor for one of 19 sampled residents (Resident 29). This failure had the potential for Resident 29 to acquire a urinary tract infection (UTI - an infection caused by bacteria entering the urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of 35 rooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents inside. This deficient practice had the potential to result in inadequate usable living space for the residents and working space for the healthcare staff.