Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montecito Post Acute Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents, one with severe cognitive impairment and another assessed as low elopement risk, were able to leave the facility unsupervised through a main lobby door that was left open and unalarmed for several hours each day. Staff discovered the absences during routine checks, and both residents were later located and returned. The lack of continuous monitoring and door security contributed to these elopement incidents.
A resident with significant medical and cognitive conditions was allowed to smoke unsupervised, contrary to facility policy requiring staff supervision and control of smoking materials. The resident accessed the smoking patio alone, obtained smoking materials, and suffered severe burns when his blanket caught fire. Staff discovered the incident only after the resident was already injured, and the event resulted in the resident being sent to a burn center for treatment.
A resident with multiple medical conditions experienced a change in condition, prompting a provider to order STAT CBC, CMP, and KUB tests. Instead of drawing blood in response to the STAT order, staff relied on a routine morning blood draw, which was later processed as STAT. The results were not reported within the facility's defined timeframe, and documentation was incomplete. Staff interviews revealed confusion about STAT lab procedures and timeframes, resulting in a failure to provide timely laboratory services as ordered.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for two residents. One resident, who had multiple diagnoses including severe dementia, altered mental status, and was identified as an elopement risk, was found missing after staff discovered the resident's wander guard device had been removed and left on the bed. The resident was later located at a hospital after being found wandering in the community. The care plan for this resident had previously identified the risk and implemented a wander guard device, but the device was not effective in preventing the elopement. Another resident, with diagnoses including toxic encephalopathy and schizophrenia, was assessed as low risk for elopement and was cognitively intact. This resident was observed moving around the facility and was later found missing from their room, with all personal belongings gone. Staff discovered the absence during routine checks, and the resident returned to the facility the following day. Interviews and video surveillance revealed that both residents exited through the same south door in the main lobby, which is left open and unalarmed for several hours daily and is not monitored during certain periods, contributing to the residents' ability to leave the facility unsupervised.
Resident Sustains Severe Burns Due to Lack of Supervision During Smoking
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, peripheral vascular disease, dementia, and cognitive communication disorder, was allowed to smoke unsupervised, resulting in life-threatening injuries. The resident had a care plan in place identifying the potential for injury related to smoking, with interventions such as maintaining smoking materials at the nurses' station and monitoring compliance with the facility's smoking policy. The resident was assessed as cognitively intact and had a recent smoking assessment indicating the need for supervision and use of a smoking apron. Despite these interventions, the resident accessed the smoking patio alone, outside of designated supervised smoke break times, and was able to obtain smoking materials. Staff interviews confirmed that the facility's policy required staff to hold all smoking paraphernalia and supervise residents during scheduled smoke breaks. However, on the day of the incident, the resident was found on the patio without staff supervision, and his blanket caught fire, resulting in burns to his face and neck. The incident was discovered by a staff member passing by, who called for help and attempted to extinguish the fire. The facility's smoking policy explicitly stated that residents were not allowed to keep smoking materials on their person and that all smoking was to be supervised at specific times. The failure to adhere to these protocols led to the resident sustaining third-degree burns and requiring emergency medical attention. Staff interviews and documentation confirmed that the resident was not being supervised at the time of the incident, and the most recent smoking assessment was not provided upon request.
Failure to Complete STAT Laboratory Test as Ordered
Penalty
Summary
The facility failed to ensure that a STAT laboratory test was completed as ordered by the physician for one resident. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, atrial fibrillation, and aortic insufficiency, was admitted to the facility and later expired there. On the day of the incident, the resident experienced a change in condition, including weakness, abdominal discomfort, diarrhea, and inability to eat. The provider was notified and gave orders for STAT CBC, CMP, and KUB tests, as well as to hold lactulose and consult infectious disease. Documentation indicated that the blood draw and KUB were completed, but the timing and process of the STAT order were inconsistent and unclear. Review of the laboratory results and facility documentation revealed discrepancies in the collection and reporting times. The STAT lab order was placed in the early afternoon, but the blood was drawn earlier in the morning as part of a routine sweep, not in response to the STAT order. The phlebotomist processed the morning blood as a STAT after the order was received, and the sample was dropped off at the lab in the afternoon. The results were not reported to the facility until the evening, well beyond the facility's defined four-hour window for STAT labs. Additionally, the requisition form for the lab was incomplete, lacking collection date, time, and draw site, and had illegible patient information. Interviews with nursing staff and administration confirmed confusion regarding the facility's policy and timeframes for STAT labs. Staff provided varying accounts of the expected turnaround time, ranging from four to six hours, and acknowledged inconsistencies in the process. The facility's policy required STAT orders to be completed as soon as possible within defined timeframes, but the actual practice did not align with this standard. The failure to complete the STAT laboratory test as ordered by the physician constituted a deficiency in providing timely, quality laboratory services to meet the needs of the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citadel Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Desert Blossom Health & Rehab Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 1.2 mi | ★★★★★ | 3 | 0 |
| Alta Mesa Health And Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Mi Casa Nursing Center | 1.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.