Health inspection·June 23, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its facility policy to re-weigh residents with a five percent (5%) or greater weight loss and immediately notify the Registered Dietician (RD) in writing for one (1) of three (3) sampled residents (Resident 1). Residents Affected - Few This failure resulted in Resident 1's increased weight loss, worsening malnutrition (not getting enough healthy food or nutrients), delayed medical treatment, and adverse consequences as evidenced by slower healing of pressure sores. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including anemia (low number of red cells in the blood), malnutrition, dysphagia (difficulty swallowing) and multiple pressure ulcers (injuries to the skin/tissue from prolonged pressure) on various areas of the body. During a review of Resident 1's Weights and Vitals Report (WVR), dated 4/19/25 - 5/28/25, the WVR indicated Resident 1 had the following weight readings: On 4/19/25, Resident 1 weighed 88.8 pounds. On 4/27/25, Resident 1 weighed 83.8 pounds, indicating a 5.63% weight loss in one week. On 5/05/25, Resident 1 weighed 81.2 pounds, indicating a 3.10% weight loss in one week. On 5/12/25, Resident 1 weighed 76.4 pounds, indicating a 5.91% weight loss in one week. On 5/18/25, Resident 1 weighed 72.2 pounds, indicating a 5.49% weight loss in one week. During a review of Resident 1's Progress Notes dated 4/28/25 to 5/28/25, there was no documentation indicating the Registered Dietitian (RD) notified of Resident 1's significant weight loss. Page 1 of 3 555830 555830 06/23/2025 Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue Lompoc, CA 93436

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/25/25 at 12:29 p.m. with the RD, the RD acknowledged that nursing staff do not communicate weight losses of five percent (5%) or greater in writing. During a concurrent interview and record review on 6/25/25 at 1:15 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022 was reviewed. The P&P indicated Any weight change of 5% (five percent) or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. The DON said we are not doing that (referring to the P&P). If we see a 5% or greater weight loss, we notify the dietician verbally .the RNA will re-weigh the resident right away. The DON acknowledged the facility's current process does not match the P&P. 555830 Page 2 of 3 555830 06/23/2025 Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue Lompoc, CA 93436

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections when: Residents Affected - Few 1. A Foley catheter bag (urine collection bag) was not touching the floor in one of three residents (Resident 1). 2. Staff didn't follow handwashing protocol per infection control standards to provide hand hygiene to one of three sampled residents (Resident 1) and one unsampled resident (Resident 2) before serving lunch meal trays. These facility failures had the potential to transmit and spread infection to residents, visitors, and staff. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur (a break in the bone between the hip and thigh bone), acute kidney failure (decline kidney function), pressure ulcers on right and left buttock and on the sacral region (injuries to the skin and underlying tissue caused by prolonged pressure on the skin), pressure induced deep tissue damage of right and left heel (injuries to the soft tissues beneath the skin, often caused by prolonged pressure or shear forces), and dysphagia (difficulty or discomfort during swallowing). 1. During an observation on 5/28/25 at 12:00 p.m., in Resident 1's room, observed a catheter bag was lying on the floor on the left side of Resident 1's bed. During an interview on 5/28/25 at 12:35 p.m., with licensed nurse (LN) 2, LN 2 acknowledged the urinary catheter bag for Resident 1 was lying on the floor. LN 2 stated that it should not be on the floor. During a review of the facility's P&P titled, Catheter Care, Urinary, dated August 2022, indicated in part, .2. Be sure the catheter tubing and drainage bag are kept off the floor. 2. During an observation on 5/28/25 at 12:17 p.m., in Resident 1 and Resident 2's room, a certified nursing assistant (CNA) 1 was observed delivering lunch trays to both Residents 1 and Resident 2 and placed them on the resident's bedside tables. The residents began eating their meal and CNA 1 walked out of the room without offering hand hygiene. During an interview with CNA 1 on 5/28/25 at 12:23 p.m., CNA 1 acknowledged not offering hand hygiene to Resident 1 and Resident 2 before they started eating. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, dated September 2022, indicated, g. Personnel assist the residents with hand hygiene before meals, after toileting and when indicated. 555830 Page 3 of 3