Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Channel Islands Post Acute during CMS and state inspections, most recent first.
A resident with a documented high fall risk score and multiple falls had a fall care plan that was not revised despite repeated incidents and an increased fall risk assessment score. The original fall care plan interventions, initiated shortly after admission, remained unchanged even after three subsequent falls and a later assessment showing a higher risk score. After a fourth fall that caused a left periprosthetic femoral fracture, the care plan interventions still mirrored the original plan. During interviews, the MDS coordinator, ADM, and ADON acknowledged that the care plan had not been updated after each fall, after the score increase, or during quarterly reviews, contrary to facility P&P requiring care plan revision with significant changes and at regular intervals.
The facility did not consistently provide the required nursing staff hours, with several days falling below mandated DHPPD and CNA minimums. During this period, multiple residents experienced falls and two were transferred to the hospital. The DON and DSD confirmed staffing shortages, which were sometimes addressed by using staff from a sister facility or administrative staff with CNA licenses.
Staff failed to promptly communicate a resident's significant change in condition, including increased fatigue, confusion, and decreased food intake, to the appropriate licensed nurse and physician. Despite CNAs observing and attempting to report these changes, inconsistencies and incomplete communication led to a delay in treatment, and the resident was ultimately sent to the hospital after further decline.
A resident with anxiety disorders and altered mental status did not have their dentures, delivered by a dental provider, documented in the inventory records, nor was their loss recorded in the theft and loss log. Staff interviews and record reviews confirmed that the inventory list was not updated and required procedures for tracking personal items were not followed, despite facility policies mandating such documentation.
Surveyors found expired medications and products available for use, improper medication administration by nursing staff, and inconsistent medication re-ordering processes. Multiple residents did not receive their prescribed medications due to pharmacy delivery delays and missing cycle medications. Additionally, the contents of an IV emergency kit did not match its label, with staff acknowledging these discrepancies and failures to follow facility policy.
A resident with a history of suicidal ideations, alcohol abuse, and opioid use was found self-administering multiple supplements without a documented assessment, care plan, or interdisciplinary team notes, contrary to facility policy requiring evaluation and documentation for self-administration of medications.
Two residents were found to be living in rooms with environmental deficiencies, including a loose floor tile creating a raised gap, cobwebs on the ceiling, wall scratches with exposed underlayer, and missing bathroom tiles. Maintenance and housekeeping logs showed no entries for these issues, and staff confirmed the problems had not been addressed as required by facility policy.
Three residents were inaccurately assessed in the MDS, with one receiving insulin injections, another taking an anticoagulant, and a third using tobacco, but these were not properly documented in their assessments. Clinical records, medication administration, and direct observations confirmed the use of these treatments and behaviors, while MDS entries failed to reflect the actual care and status of the residents.
The facility did not complete required PASRR Level I and Level II screenings for two residents with mental health diagnoses. One resident was admitted with schizophrenia and bipolar disorder but had no PASRR Level I screening on file, while another resident with psychosis had a positive Level I screening for serious mental illness but no Level II evaluation was completed. The DON confirmed these omissions during interviews.
Medications requiring refrigeration, such as PPD, insulin, and hepatitis vials, were found stored in a medication refrigerator at 32°F, which is below the facility's policy range of 36°F to 46°F. An RN confirmed the out-of-range temperature and that the medications were not stored as required.
Dietary staff did not label or date several food items in storage, including stuffing packets, bread buns, and hamburger patties, as required by facility policy. The Assistant Administrator confirmed these deficiencies during an inspection.
A resident with multiple medical conditions was discharged home with the expectation of receiving home health services, but the facility did not confirm that these services were in place before discharge. The resident did not receive the needed care, contacted the facility for assistance, and reported a fall after discharge. Facility staff did not follow up with the home health agency or the resident to ensure continuity of care, and authorization from the VA was still pending.
A resident's personal belongings, including a cell phone and reading glasses, were mistakenly relocated to another room due to staff miscommunication about the resident's COVID-19 isolation status. The resident, who has COPD, CHF, and pneumonia, experienced agitation and accused staff of taking his phone. The items were later found and returned.
A facility failed to implement a comprehensive care plan for a resident with an ADL self-care deficit, despite the resident's diagnoses of COPD, CHF, and pneumonia. The care plan did not adequately address the resident's need for assistance with tasks like toileting, as required by the facility's policy, placing the resident at risk of unmet care needs.
A resident in a LTC facility, requiring assistance with ADLs due to conditions like COPD and CHF, was left waiting for over an hour for a urinal, resulting in urination on himself. The resident's care plan highlighted the need for staff assistance due to muscle weakness and a deep tissue injury. Other residents reported similar delays in staff response, indicating a broader issue with call light wait times.
The facility failed to ensure that residents with a positive Level I PASRR received a Level II evaluation. Two residents with significant mental health histories did not have their cases reopened for Level II evaluations as directed by the Department of Health Care Services. The DON was unaware of the need to resubmit Level I PASRRs after the initial cases were closed.
The facility failed to ensure a safe environment by leaving unsecured medications in resident rooms without proper assessment or authorization for self-administration. This affected two residents, one with diabetes and another with spinal stenosis, who had medications left at their bedside without staff supervision.
Failure to Revise Fall Care Plan After Increased Fall Risk and Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s comprehensive fall care plan in response to increased fall risk scores and multiple subsequent falls. The resident had an initial fall risk score of 10 on admission, categorizing them as high risk, and a fall care plan for falls was initiated on 8/20/25 and revised on 8/30/25. Despite this, there was no documentation of updated interventions after the resident experienced falls on 10/17/25, 11/27/25, and 12/11/25. A follow-up Fall Risk Evaluation on 2/25/26 showed the resident’s score had increased to 17, still indicating high risk, and the facility’s own Fall Risk Evaluation Form stated that a score of 10 or greater requires immediate initiation and documentation of preventive protocols. However, the comprehensive care plan interventions remained unchanged from the original 8/20/25 plan. The resident subsequently experienced a fourth fall on 3/31/26, which resulted in a left periprosthetic femoral fracture. While this fall was addressed, the interventions in the care plan still remained identical to those originally established on 8/20/25. During interviews and concurrent record reviews, the MDS coordinator confirmed the history of four falls and acknowledged that the care plan had not been revised following the increased fall risk score, each fall, or during quarterly reviews, and could not explain the lack of updates. The Administrator and ADON also acknowledged that facility policies and procedures were not followed, despite written policies stating that care plans must be revised quarterly, annually, and upon significant changes in condition, and that comprehensive assessments and significant changes require IDT review and/or revision of the care plan.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where the Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) hours fell below the required minimums. Record review showed that on several dates, the actual DHPPD and CNA hours did not meet the 3.5 and 2.4 minimums, respectively, as mandated by state guidelines. The Director of Nursing (DON) validated these findings during a concurrent interview and record review. The Director of Staff Development (DSD) confirmed that the facility has implemented CNA classes and occasionally receives staffing support from a sister facility or administrative staff who are licensed CNAs, but last-minute call-ins due to family emergencies have contributed to staffing shortages. A review of facility fall logs during the period of insufficient staffing revealed multiple resident falls and two hospital transfers. Specifically, one resident fell on one date, two residents fell on another, and two residents fell on a subsequent date, with two hospital transfers occurring during the same timeframe. There were no reported missed or medication errors within the period reviewed. The facility's policy on adequate staffing states that sufficient staff must be maintained on each shift to meet resident needs, but the documented staffing levels did not consistently meet this standard.
Failure to Communicate Change in Condition Resulting in Delay of Treatment
Penalty
Summary
Facility staff failed to ensure prompt communication of a significant change in condition for one resident, resulting in a delay in treatment. The resident, who had a history of alcohol cirrhosis with ascites, hepatic encephalopathy, pleural effusion, heart failure, and generalized swelling, experienced increasing fatigue, confusion, and difficulty eating. Certified Nursing Assistants (CNAs) observed these changes, including the resident becoming more tired, needing assistance with meals, eating less, and displaying confusion and altered speech. Although CNAs reported some changes to licensed nurses, there were inconsistencies in communication, with one CNA later admitting to the Assistant Administrator that she had not reported the change in condition to the nurse as initially claimed. Licensed nurses did not receive complete or timely information about the resident's altered mental status and physical decline. As a result, the resident's significant change in condition, including weakness, dysphagia, and altered level of consciousness with abnormal vital signs, was not promptly communicated to the physician. The delay in recognizing and reporting these changes led to a delay in treatment, and the resident was eventually sent to the hospital after further decline was noted. Review of facility policy confirmed that staff were required to report such changes to licensed nurses, but this procedure was not followed.
Failure to Document and Track Resident's Dentures
Penalty
Summary
The facility failed to ensure that a resident's right to retain and use personal possessions was honored when a set of dentures delivered to the resident was neither documented in the inventory records nor subsequently located. The resident, who had diagnoses including anxiety disorders and altered mental status, was admitted with a process in place for documenting personal belongings. However, review of the resident's records showed that the dentures, delivered by a dental provider, were not entered into the inventory of personal effects, and there was no record of their loss in the theft and loss log. Multiple staff interviews confirmed that the inventory list had not been updated since admission, and the required procedures for documenting and tracking personal items were not followed. Observations of the resident revealed a sunken facial appearance, and staff interviews indicated that packages and personal items are typically logged, labeled, and added to the inventory list. Despite these procedures, the dentures were not accounted for, and staff responsible for maintaining these records were unaware of the missing item. Review of facility policies confirmed that all personal items, especially those affecting health and safety, should be documented and tracked, but these policies were not adhered to in this case.
Expired Medications, Missed Doses, and Medication Management Failures
Penalty
Summary
The facility failed to adhere to its pharmaceutical services policies in several key areas. Surveyors observed that expired medications and products, including a nutritional shake, sodium chloride, acetic acid, estradiol cream, and an inhaler, were available for resident use. Nursing staff acknowledged the presence of these expired or improperly stored items and confirmed that they should have been discarded according to facility policy. Additionally, a nurse administered more eye drops than ordered by the physician to a resident, contrary to the documented medical order and facility procedures for medication administration. The facility did not maintain a consistent medication re-ordering process, as evidenced by multiple entries in the re-ordered medication binder showing that numerous residents were either out of medications or had only a few doses left. Nursing staff stated that medications were supposed to be ordered five days in advance, but this was not consistently done. Furthermore, the facility did not ensure timely and consistent availability of resident medications. Several residents did not receive their prescribed medications due to delays in pharmacy delivery or missing cycle medications, and staff interviews confirmed that this was a recurring issue. The facility's agreement with the pharmacy for monthly cycle medication refills was not being fulfilled as planned. Surveyors also found discrepancies in the contents of the intravenous emergency kit, where two bags of sodium chloride were present but not listed on the kit's label. Nursing staff acknowledged that the kit contents did not match the label and stated that the pharmacy was responsible for ensuring accuracy. These failures collectively had the potential to negatively impact resident care and safety, as the facility did not follow its own policies for medication storage, administration, re-ordering, and emergency kit management.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident was found with multiple self-administered medications, including Primal Harvest Hair Growth Complex, Immuneti Advanced Immune Defense, and Primal Multivitamins, at their bedside. The resident reported self-administering these supplements since admission. The resident's medical record indicated a history of suicidal ideations, alcohol abuse, and opioid use. No self-administration assessment was completed for the resident, and there was no documentation of the resident's desire to self-administer medications. Additionally, there were no interdisciplinary team notes or care plan entries regarding self-administration, despite facility policy requiring assessment, documentation, and care planning for residents who wish to self-administer medications. Nursing staff and facility leadership confirmed the absence of required documentation and assessments.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room was observed to have a loose floor tile that was partially lifted, creating a raised gap. Review of the maintenance logbook for the relevant section of the facility showed no requests or entries for floor tile repairs in this resident's room or bathroom. During an interview and observation with the Maintenance Supervisor, the issue was confirmed, and it was acknowledged that the problem existed. In another case, a different resident's room was found to have cobwebs hanging from the ceiling above the bed, visible scratches with paint coming off the wall behind the headboard, and missing tiles around the bathtub in the bathroom, exposing residue on the wall. The maintenance logbook for this section also showed no entries for maintenance work in this room. The Maintenance Supervisor confirmed the presence of these issues and stated that repairs had not yet been completed. The Laundry and Housekeeping Supervisor and District Manager of Laundry and Housekeeping Services acknowledged that the room had been overlooked. Facility policy requires housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, and staff are expected to report findings directly or add them to the maintenance logbook.
Inaccurate MDS Assessments for Injections, Anticoagulant, and Tobacco Use
Penalty
Summary
The facility failed to accurately assess and document the clinical status of three residents in the Minimum Data Set (MDS) assessments. One resident with a diagnosis of Type 2 Diabetes was prescribed and administered insulin injections as documented in the Medication Administration Record and physician's notes, but the MDS assessment incorrectly indicated that the resident did not receive any injections during the observation period. Another resident was prescribed and received Apixaban, an anticoagulant, as confirmed by physician orders and the Medication Administration Record, yet the MDS assessment inaccurately recorded that the resident did not receive any anticoagulant medication during the look-back period. In both cases, the MDS coordinator acknowledged the discrepancies between the clinical records and the MDS entries during interviews and record reviews. A third resident, who was documented as a smoker in the physician's notes and a smoking evaluation, and was observed both with a vaping device and smoking cigarettes on facility grounds, was incorrectly assessed in the MDS as not using any form of tobacco. The MDS coordinator confirmed the inaccuracy after reviewing the resident's records and observations. These failures to accurately assess and document the residents' clinical statuses in the MDS have the potential to result in care needs not being properly identified or addressed.
Failure to Complete Required PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required PASRR (Preadmission Screening and Resident Review) Level I and Level II screenings were completed for two residents with mental health diagnoses. For one resident admitted with diagnoses including unspecified schizophrenia and bipolar disorder, there was no evidence of a PASRR Level I screening in the medical record from the time of admission through the date of review. The Director of Nursing confirmed that the PASRR Level I screening was missed for this resident. For another resident admitted with a diagnosis of unspecified psychosis, the pre-admission PASRR Level I screening indicated a positive result for serious mental illness, which required a Level II mental health evaluation. However, there was no documentation of a Level II PASRR evaluation in the medical record from the time of the positive Level I screening through the date of review. The Director of Nursing confirmed that the PASRR Level II evaluation was not completed for this resident. The facility's policy requires Level I screenings for all admissions and Level II evaluations when indicated, but these procedures were not followed in these cases.
Improper Refrigeration of Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration, including Tuberculin (PPD), insulin, and hepatitis vials, were stored in a medication refrigerator with a temperature reading of 32°F, which is below the facility's policy requirement of 36°F to 46°F (2°C to 8°C). During the observation, a registered nurse confirmed the temperature was outside the acceptable range and acknowledged that the medications were not stored according to policy. The facility's policy specifies that medications needing refrigeration must be kept within the specified temperature range and monitored with a thermometer, with maintenance notified if temperatures are out of range. The improper storage temperature was directly observed and confirmed by staff during the survey.
Failure to Label and Date Stored Food Items
Penalty
Summary
The facility failed to ensure that dietary staff properly labelled and dated food items in storage, as observed during a kitchen inspection. Specifically, three packets of traditional stuffing were found with only a date received and no indication of the date opened or expiry date. Additionally, an open bag of bread buns and a bag containing four hamburger patties were found in the freezer section without any date markings or expiry dates. The Assistant Administrator acknowledged these findings during the observation. A review of the facility's policy on labeling and dating foods indicated that staff are responsible for marking the date at the time of processing and/or storage, and that a use-by date must be provided for all food items.
Failure to Ensure Home Health Services in Place Prior to Discharge
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident who was discharged home with the expectation of receiving home health services. The resident, who had a history of a right acetabulum and pubis fracture, Type 2 Diabetes Mellitus, and long-term insulin use, was discharged with arrangements for physical therapy, occupational therapy, and nursing services through a home health agency (HHA). Although the facility's social services staff faxed referral documents to the HHA, there was no evidence that the facility confirmed receipt of the referral or that services were in place prior to discharge. After discharge, the resident contacted the facility to report that he had not received the expected caregiver services and had already experienced a fall at home. Interviews with facility staff revealed that the social services department did not typically follow up with HHAs or discharged residents unless notified by the HHA of an issue. The HHA reported they had not seen the resident because they were awaiting VA authorization and had been unable to contact the resident. Documentation showed that the VA had not processed the authorization request in a timely manner, and the HHA had not received the necessary information to proceed. The facility's policy required social services to ensure continuity of care during discharge, but in this case, the lack of confirmation and follow-up resulted in the resident not receiving needed home health services.
Resident's Personal Belongings Misplaced Due to Staff Miscommunication
Penalty
Summary
The facility failed to honor a resident's right to retain and use personal possessions, resulting in a deficiency. This incident involved a resident who was admitted with chronic obstructive pulmonary disease, congestive heart failure, and pneumonia. The resident's personal belongings, including a cell phone, charger, and reading glasses, were mistakenly relocated to another room. This occurred due to a miscommunication among staff regarding the resident's COVID-19 isolation status. The resident experienced agitation and made verbal accusations towards the staff, claiming that his phone was taken away. A licensed nurse confirmed the resident's complaint and explained that the certified nursing assistant had transferred the resident's belongings to another room due to the misunderstanding about the resident's isolation status. The items were eventually found and returned to the resident. The facility's policy on resident rights emphasizes the importance of allowing residents to keep and use personal possessions unless it infringes on the rights or safety of others.
Failure to Implement Comprehensive Care Plan for Resident with ADL Deficit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for a resident with an activities of daily living (ADL) self-care deficit. This deficiency was identified during a review of the resident's clinical record, which revealed that the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and pneumonia. The comprehensive care plan dated 6/10/24 indicated that the resident had an ADL self-care deficit related to muscle weakness and unsteady gait, requiring staff assistance for various tasks such as washing hands, adjusting clothing, and using the toilet. However, the facility's policy and procedure for care planning, revised in 11/2023, mandates that the interdisciplinary team (IDT) implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's needs. The review of the resident's admission Minimum Data Sheet (MDS) dated 6/16/24 showed that the resident had moderate cognitive impairment and required assistance for ADLs, but the care plan did not adequately address these needs. This oversight placed the resident at risk of not having their care needs met due to the lack of a proper plan.
Delayed Assistance with Toileting Leads to Resident Incident
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident 1, who required help with activities of daily living, specifically toileting. Despite the resident's request for a urinal, staff did not respond for over an hour, resulting in the resident urinating on himself. This incident was documented in a complaint report, where the resident expressed concerns about staff not listening to his needs, including issues with his mattress, toothbrush, and television, in addition to the delayed response for toileting assistance. Resident 1 had been admitted for post-acute care therapy with multiple diagnoses, including COPD, CHF, pneumonia, muscle weakness, and unsteadiness on feet, necessitating assistance with personal care. The resident's care plan indicated a need for staff assistance with various ADLs due to an ADL self-care deficit and a deep tissue injury requiring protection from excessive moisture. Interviews with other residents revealed that call light response times were often delayed, with one resident stating an average wait time of 15 minutes or more, and another reporting waits of 20 minutes or longer for assistance, including pain medication.
Failure to Ensure Level II PASRR Evaluations
Penalty
Summary
The facility failed to ensure that residents with a positive Level I Preadmission Screening and Resident Review (PASRR) received a Level II evaluation. Specifically, after the cases for two residents were closed, the facility did not resubmit Level I PASRRs to reopen the cases as directed by the Department of Health Care Services. This failure was identified during interviews, record reviews, and policy reviews conducted by surveyors. Resident #80, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and paranoid schizophrenia, was readmitted to the facility. Despite having a positive Level I screening, the Level II evaluation was not scheduled due to the resident being isolated as a health or safety precaution. The Director of Nursing (DON) was unaware that a new Level I should have been completed to reopen the case after the Level II evaluation was closed. Similarly, Resident #5, who had a medical history including bipolar disorder, major depressive disorder, anxiety disorder, hydrocephalus, traumatic brain injury, and schizoaffective disorder, also had a positive Level I screening. The Level II evaluation was not scheduled because the resident was unable to participate. The DON did not review the reason for the evaluation's non-completion and was unaware that a new Level I should have been completed to reopen the case.
Unsecured Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure the residents' environment remained as free of accident hazards as possible when unsecured medications were observed in residents' rooms without staff present. This deficiency affected Resident #33, who had a medical history including type two diabetes mellitus and gastro-esophageal reflux disease, and Resident #65, who had a medical history including spinal stenosis and depression. Both residents had medications left unsecured in their rooms without proper assessment or authorization to self-administer their medications. Resident #33 was observed with two medications on their bedside table, which they stated were for their stomach and diabetes. The nurse had left the medications in the room, and the resident indicated they would take them when ready. The nurse confirmed that medications should not be left at the bedside and admitted not knowing if the resident had been assessed to self-administer. Further interviews revealed that the nurse did not stay with the resident to ensure the medications were taken, contrary to facility policy. Resident #65 was found with a bottle of Osteo-Biflex on their bedside table, which was not included in their medical orders. The resident stated they had been taking the supplement since admission and had informed their physician, who approved its use. However, there was no documentation or assessment for self-administration. The DON and Administrator confirmed that medications should be securely stored and inaccessible to residents unless they had been assessed and authorized to self-administer, which was not the case for Resident #65.
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Illustrative
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Barbara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valle Verde Health Facility | 1.2 mi | ★★★★★ | 7 | 0 |
| Samarkand Skilled Nursing Facility | 1.4 mi | ★★★★★ | 4 | 0 |
| Mission Park Healthcare Center | 1.5 mi | ★★★★★ | 0 | 0 |
| The Californian | 1.9 mi | ★★★★★ | 0 | 0 |
| Buena Vista Care Center | 3.4 mi | ★★★★★ | 15 | 1 |
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