Health inspection·August 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement a care planned intervention, to monitor meal intake percentage, and to offer a meal alternative, if less than 50% of a meal was consumed, for one of two sampled residents (Resident 1). This facility failure had the potential to be a contributing factor in Resident 1's weight loss, while at the facility. Findings: During a concurrent record review and interview on 8/11/23, starting at 9:33 a.m., with the Assistant Director of Nursing (ADON 1) and the Medical Records Assistant (MRA 1), Resident 1's medical record was reviewed. Resident 1's Care Plan indicated in part. At risk for altered nutritional status r/t (related to) inadequate energy intake with an approach/task to Monitor food intake and record every meal. If resident (Resident 1) consumes less that 50% of meal offer alternative. This care planned problem and approach/task was initiated when Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Documentation Survey Report (a form used by facility staff that tracks a residents meal intake percentage and if a meal alternative was offered) was reviewed. This form indicated, on 7/5/23, 7/6/23, 7/10/23, 7/16/23, 7/17/23, 7/18/23, 7/23/23, 7/25/23 and 7/26/23, staff failed to document a combination of Resident 1's meal intake percentage, if a meal alternative was offered when Resident 1 refused a meal, and/or ate 25% or less of a meal. The ADON 1 and MRA 1 reviewed the document and acknowledged on those dates, staff either failed to document Resident 1's meal intake percentage, or if Resident 1 was offered a meal alternative when refusing a meal or eating 25% or less of a meal. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/22, the P&P indicated in part, The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555830 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue Lompoc, CA 93436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)