Montecito Post Acute Care and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for 2 (residents #22 and #19) of 5 sampled residents. The deficient practice could result in injury to residents.-Regarding Resident #22Resident #22 was readmitted to the facility on [DATE] with diagnoses including: Metabolic encephalopathy, cognitive communication deficit, restlessness and agitation, chronic kidney disease, , muscle weakness, difficulty in walking, protein-calorie malnutrition, altered mental status, seizures, type 2 diabetes mellitus with hyperglycemia, unspecified mood affective disorder, anxiety disorder, tobacco use, major depressive disorder, dementia, severe, without behavioral disturbance, psychotic disturbance, and mood disturbance. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. The assessment also indicated that the resident was dependent on staff assistance when moving from a laying to sitting position, and that the ability to get on and off the toilet was not assessed due to a medical condition or safety concern. An interview was conducted on February 11, 2024, at 10: [...]

Inspectors wroteBased on record review, resident and staff interviews and observations The facility failed to ensure proper nail care for one of thirty-six sampled residents (#104) was performed. This deficient practice could result in resident grooming and hygiene needs not being met.

Inspectors wroteBased on review of clinical records and policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for one Resident (#288). The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure one resident was free from unnecessary medication by failing to ensure there was a adequate indication for the use of antibiotic medication for one resident (#193). The deficient practice could result in residents receiving unnecessary antibiotics which could result in infectious microorganisms with increased drug resistance and/or superinfection.

Inspectors wroteBased on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure preferences regarding meals were honored for one resident (#287). The deficient practice could result in resident's autonomy not exercised.

Inspectors wroteBased on clinical documentation, resident and staff interviews, and facility policy, the facility failed to ensure treatment was administered as ordered by the physician for one resident (#27). The deficient practice could result in resident not receiving care and services based on his assessed needs.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy review, the facility failed to maintain accurate, complete, and readily accessible medical records in accordance with professional standards and practices for four residents (#101, #39, #70, & #487). The sample size was 35 residents. The deficient practice could result in additional medical records being inaccessible and unavailable to reflect the care and services provided to residents.

Inspectors wroteBased on observation, staff interviews, policy review, and the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement their infection control and prevention program related to perineal/catheter care. The deficient practice could result in transmission of infection to staff and residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and review of policy and procedure, the facility failed to ensure one sampled resident's (#133) right to self-determination. The deficient practice could result in infringement of resident rights.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#39) was provided written notification for a bed hold when transferred to the hospital. The sample size was 2 residents. The deficient practice could result in residents that are transferred or discharged not being informed of the facility's bed hold policy in writing.

Inspectors wroteBased on clinical record review, staff interviews, policy review, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (#133). The sample size was 35 residents. The deficient practice could result in assessments that are not accurate and data that is not accurate for quality monitoring.

Inspectors wroteBased on staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#178) weight was obtained as ordered. The sample size was 4 residents. Failure to obtain and monitor weights could result in weight loss and malnutrition.

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure percutaneous endoscopic gastrostomy (PEG) tube care was provided for one sampled resident (#70). The deficient practice could result in the resident's increased risk for infection.