Aviata at Santa Barbara

Inspectors wroteBased on record review, review of facility's policy and procedure and staff interviews, the facility failed to provide immediate and appropriate basic life support to 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). On [DATE] at approximately 2:07 a.m., the clinical staff consisting of one Registered Nurse (RN) and one Licensed Practical Nurse (LPN) administered Cardiopulmonary resuscitation (CPR) to Resident #1 when he was found without a pulse or respirations. The Licensed Nurses did not activate Emergency Medical Services (EMS) and discontinued CPR after approximately 20 minutes. The RN pronounced the resident's death without the required credentials. Clinical staff re-started CPR 4 hours later at the direction of the Director of Nursing and called EMS. [...]

Inspectors wroteBased on record review, review of facility policies and procedures, and staff interviews, the facility failed to ensure clinical staff had the competencies to respond appropriately to emergencies and ensure 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) received timely life saving measures when found without pulse or respirations. Resident #1 had a full code status. On [DATE], Resident #1 was found in cardiac and respiratory arrest. Clinical staff administered cardiopulmonary resuscitation (CPR) for 20 minutes then pronounced the resident's death without authority to do so and without activating Emergency Medical Services (EMS). Clinical Staff re-started CPR and activated EMS 4 hours after CPR was stopped and the resident had no pulse and respirations. [...]

Inspectors wroteBased on record review, review of facility's policies and procedures, resident representative and staff interviews, the facility failed to allow the return to the facility post hospitalization for 1 (Resident #2) of 7 residents reviewed for discharge planning process. Resident #2 was discharged to a different nursing home approximately 73 miles from his family.

Inspectors wroteBased on review of the clinical record, resident representative and staff interview the facility failed to have documentation of incontinent care to meet the needs of 1 (Resident #999) of 4 residents reviewed for toileting needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to prevent verbal abuse from staff for 2 of 3 residents reviewed. (Patient #1 and Patient #2)

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to ensure staff provided incontinence care in accordance with accepted standards of care to meet the needs of 1 (Resident #800) of 3 residents reviewed.

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, residents and staff interviews the facility failed to have processes in place to prevent avoidable accidents for 6 (Residents #3, #103, #59, #74, #5, #95) of 6 residents by failure to accurately assess smoking risks, failure to identify unsafe storage and use of ignition devices where oxygen is in use and failure to adequately supervise residents who smoke tobacco products and electronic cigarettes. Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen. On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and a lighter approximately 4 feet from Resident #103 who was receiving oxygen. [...]

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to ensure licensed nurses had the appropriate training and competencies to complete accurate smoking risk evaluations and identify unsafe smoking practices. The smoking risk evaluations for 7 (Residents #59, #105, #3, #74, #64, #5, #95) of 7 residents reviewed contained conflicting, inaccurate information and did not accurately reflect the residents' abilities to smoke independently. Each smoking evaluation noted the resident was a safe smoker and needs constant supervision.4 (Residents #3, #5, #59, and #74) of 4 residents observed with oxygen in use in their rooms were allowed to store ignition devices in their rooms while oxygen was in use. [...]

Inspectors wroteBased on observation, record review, residents and staff interviews, the facility administration failed to utilize its resources effectively to provide effective oversight and enforcement of safe smoking practices. The smoking evaluations for 5 (Residents #59, #3, #74, #64 and #5) of 6 residents reviewed contained conflicting and inaccurate smoking risks. The evaluations noted the residents were safe smokers and required constant supervision for smoking. The licensed nurses who completed the smoking evaluations had no documentation of training or competencies to ensure the smoking evaluations were complete and accurately reflected each resident's smoking risks. Residents #3, and #59 were smokers and used supplemental oxygen in their rooms. Resident #5 used oxygen and vaped electronic cigarettes in her room. [...]

Inspectors wroteBased on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's supervised smoking policy to ensure accurate residents' smoking evaluations and prohibiting the use and storage of ignition devices around oxygen use in residents' rooms for 6 (Residents #3, #103, #59, #74, #5, and #95) of 6 residents reviewed for safe smoking. Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen via nasal cannula. On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and lighter approximately 4 feet from Resident #103 who was in bed receiving supplemental oxygen. Residents #59 and #74 were roommates and smokers. Resident #59 received supplemental oxygen. [...]

Inspectors wroteBased on record review and interview, the facility failed to have a written transfer agreement in effect with one or more hospitals approved for participation in Medicare/Medicaid programs.

Inspectors wroteBased on record review, review of facility's policy and procedure, residents and staff interviews, the facility failed to act promptly upon the grievance expressed by the resident council group during their monthly meetings.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to provide appropriate care and services to prevent complications of enteral feeding tubes for 3 (Residents #52, #15 and #94) of 4 residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure timely acquiring and administering of medications to meet the needs of 3 (Residents #48, #51, and #18) of 3 residents selected for medication administration observation.

Inspectors wroteBased on record review, review of the facility's policy and procedure, and staff interview, the facility failed to ensure 2 (Residents #65, and #51) of 5 residents reviewed for immunization received education regarding the benefits and potential side effects and were offered pneumococcal immunization. The facility failed to ensure 1 (Resident #65) of 5 residents residing at the facility between October 1, 2024, and March 31, 2025, received education and was offered the influenza immunization.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #15 and #57) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability.

Inspectors wroteBased on record review, review of facility's policy and procedure and staff interview the facility failed to refer 1 (Resident #11) of 2 residents with signs of serious mental illness, intellectual disability or a related condition for a Level II Pre admission Screening and Resident Review as required.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing program of activities to meet the needs of 1 (Resident #113) of 3 reviewed for activities program.

Inspectors wroteBased on record review, review of the facility's policies and procedures and staff interviews, the facility failed to have documentation of COVID-19 vaccination status, screening, education, and offering of the vaccine for 1 (Resident #65) of 5 residents reviewed for immunization status.

Inspectors wroteBased on record review and interview, the facility failed to ensure 3 (Residents #1, #2 and #3) of 3 residents reviewed received care and services in accordance with professional standards of practice by failing to ensure laboratory testing were done as ordered for Residents #1, #2, and #3. The facility failed to document family reported concerns and failed to notify the practitioner of several episodes of loose stools for Resident #1.

Inspectors wroteBased on record review and interview, the facility staff failed to follow processes to ensure laboratory testing were done as ordered to meet the needs of 3 (Residents #1, #2 and #3) of 3 residents reviewed.

Inspectors wroteBased on observations, interview, and record review the facility failed provide appropriate interventions to prevent falls for 2 (Residents #1, and #2) of 3 residents surveyed with a history of falls with major injury. Failure to provide appropriate fall interventions creates a potential for falls and fall related injuries to the residents.

Inspectors wroteBased on record review, review of facility's policy and procedure review, and staff interviews, the facility failed to report an injury of unknown source and serious bodily injury was reported to the State Survey Agency within the prescribed timeframe for 1 (Resident #1) of 1 resident reviewed.

Inspectors wroteBased on observation, review of facility policy and procedure, clinical record review and staff interviews, the facility failed to provide appropriate services and interventions to maintain function and prevent the decline in range of motion for 2(Resident #19 and #24) of 3 residents sampled with a limitation in range of motion (ROM).

Inspectors wroteBased on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin pens were properly labeled and dated when opened in 2 (Cart #4 and #5) of 3 medication carts reviewed. This had the potential for residents to receive medications that could create hazardous health consequences.

Inspectors wroteBased on record review, review of facility policy and staff interviews, the facility failed to provide the Skilled Nursing Advance Beneficiary Notice of Non-coverage to 1 (Resident #31) of 3 residents who was discharged from Medicare Part A services but remained at the facility.

Inspectors wroteBased on observation, review of facility policy, and staff interviews, the facility failed to ensure proper storage of medications in 1 (Medication cart #4) of 3 medication carts reviewed for proper storage and labeling of medications.