Instead of the traditional bariatric mattress the bed was designed to work with, Resident B had a low air loss mattress inside it.
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Inspectors classified the deficiency as isolated, meaning it did not appear to be a pattern running through the entire operation.
The inspection at Advanced Rehabilitation & Healthcare of Live Oak, completed in November 2025, turned on a single piece of paper.
Federal inspectors visited the facility on November 13, 2025, following a complaint.
The violation was tagged under F0656, which covers the development and implementation of comprehensive care plans.
Inspectors found Avir at Longview had not done that.
R4 told inspectors that his room was cleaned daily, with one exception: the days when V14, the housekeeper assigned to his room, was on duty.
The citation fell under what federal inspectors classify as a pattern violation, meaning this wasn't a single lapse on a single day.
Federal inspectors cited the facility on November 13, 2025, following a complaint investigation.
That is what inspection records show happened at Casa Dorinda, a Santa Barbara nursing facility, in late September 2025.
The citation was not a near-miss.
The citation, recorded under F0744, covers a cluster of failures that inspectors found working together.