Montecito Post Acute: Elopement Door Left Unalarmed - AZ
The resident, identified in inspection records as Resident 19, had been seen earlier that night walking the facility's floors looking for snacks. At some point after that, she walked out. A licensed practical nurse told inspectors she had no idea how the resident got out, because she believed the door alarms were working.
They weren't. Not because they were broken, but because nobody had turned them on.
The director of nursing confirmed to inspectors on September 4, 2025, that the south door in the main lobby, the same door both Resident 19 and a second resident identified as Resident 22 used to leave the building, runs without any alarm from 5 a.m. to 10 p.m. every single day. That is seventeen hours each day when any resident, including those flagged as elopement risks, can walk straight out the front of the building without triggering any alert.
A receptionist is posted at the front desk and keeps photographs of residents considered at risk of elopement. But that receptionist is only scheduled from 8 a.m. to 7 p.m. For six hours every day, the entrance is entirely unmonitored.
Resident 22 eloped first. Then Resident 19 used the same door to leave the same way. The facility's own investigation reports, completed after each incident, concluded that both elopements were isolated events. The facility is now disputing the federal citation that followed.
LPN #274, who was on shift the night Resident 19 disappeared, told inspectors she left work at 6:30 a.m. on August 18. Before she clocked out, she saw Resident 19 walking back into the facility, accompanied by the facility administrator. The inspection report does not say where Resident 19 had been, how long she had been outside, or what condition she was in when she returned.
What the report does say is that two residents left through the same door, that the door is designed to be open and unalarmed for most of the day, that the only human check on that entrance is a receptionist who isn't scheduled during the hours before sunrise or after early evening, and that after both residents walked out, the facility's internal review reached the same conclusion each time: nothing systemic, just an isolated incident.
Federal inspectors disagreed. The citation, tagged F0689 and covering resident elopement and accident prevention, was rated as causing minimal harm or potential for actual harm. The facility has formally contested it.
The inspection report does not describe what elopement risk designations either resident carried, or whether those designations were documented in their care plans. It does not say whether either resident had dementia or any other condition that would make unsupervised outdoor access dangerous. It does not describe what the facility administrator found when he located Resident 19 outside, or how far she had gotten.
What it describes is a gap that was not accidental. The door is open without alarm by design, on a schedule, every day. The receptionist coverage ends hours before the alarm-free period does. The facility's own elopement policy, last revised in January 2022, states that residents at risk of elopement are to be properly monitored. Two residents left through the same unmonitored exit within days of each other, and the facility's response was to call each one a coincidence.
LPN #86, who was on duty when staff realized Resident 19 was missing, told inspectors she genuinely believed the door alarms were functioning. She had no reason to think otherwise. The alarm-free window is built into the facility's daily operations, and it is not clear from the inspection record how many staff members understood that the south lobby door goes unalarmed for the better part of every day.
Resident 19 came back. The facility administrator walked her in before the morning shift ended. The inspection report does not say whether anyone asked her where she had gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Montecito Post Acute Care and Rehabilitation from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
Montecito Post Acute Care and Rehabilitation in MESA, AZ was cited for violations during a health inspection on September 4, 2025.
The resident, identified in inspection records as Resident 19, had been seen earlier that night walking the facility's floors looking for snacks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.