Lompoc Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications, biologicals or supplies were properly disposed of and not readily available for use and unlabeled prepared medications were not stored in the medication cart. These failures may pose a significant risk to residents' health and safety by potentially exposing them to ineffective treatments or therapies and medication errors.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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: 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents, (Resident 62), self-administration of medication was with interdisciplinary team (IDT- healthcare professionals from different specialties working together to provide patient care) approval and determination as clinically safe and appropriate. This failure had the potential for Resident 62 to unsafely self-administer medication.

Inspectors wroteBased on observation interview and record review, the facility failed to have the most current survey results accessible to the public, in the facility survey results binder. This facility failure denied the opportunity for residents, family members, and legal representatives of residents, to be aware of the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow care plan (a document that summarizes how a patient's needs will be met, and their care will be managed) interventions for call lights, for two of 23 sampled residents (Resident 17 and Resident 44) when: 1. Resident 44's call light was out of reach, on the floor. 2. Resident 17's call light was out of reach. These failures had the potential for Resident 44 and Resident 17's needs to go unmet by staff.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders for three of 23 sampled residents (Resident 93, Resident 32, and Resident 12) when the facility staff did not: 1. Check Resident 93's blood pressure prior to the administration of hydralazine (a medication used to treat blood pressure). This failure had the potential for Resident 93 to receive Hydralazine, against physician orders, secondary to no monitoring. 2. Weigh Resident 32 per physician orders. This failure had the potential to adversely affect Resident 32's heart condition. 3. Check Resident 12's blood pressure prior to the administration of Lisinopril (a medication used to treat blood pressure). This failure had the potential for Resident 12 to receive Lisinopril, without following the precautionary parameters ordered by the physician.

Inspectors wroteBased on observation and interview, the facility failed to ensure emergency drugs were available to residents when ordered. The facilities Emergency Drug Supply Kit (E-Kit) was not re-ordered timely after being opened for use. This failure had the potential for emergency drugs to not be available during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as directed and ordered when: 1. Resident 72 was not given /administered with Insulin (a medication to lower blood sugar levels) when the resident's blood sugar level /reading went above the parameter set by the physician. 2. Resident 42 was not administred with Diltiazem (medication for high blood pressure )when the resident's blood pressure level was above the parameter set by the physician. These failures had the potential medication errors secondary to non administration as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Six opened nebulizer (turns medicine into a mist) medications were labeled with opened dates for two sampled residents (Resident 11 and Resident 94) and three unsampled residents (Resident 43, Resident 103, and Resident 463) per facility policy. 2. Three expired test strips in one medication cart were discarded and not readily available for staff use. These failures had the potential for residents to receive expired and ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medical records for three out of 23 residents (Resident 17, 37, 94) accurately documented POLST (Physician Orders for Life-Sustaining Treatment (gives instructions for care in life-threatening medical situations) information in the electronic medical record (EMR) when: 1. Resident 94's POLST did not match the electronic health record. 2. Resident 37's POLST did not match the electronic health record. 3. Resident 17's POLST did not match the electronic health record. These failures had the potential to result in Residents 17, 37, and 94 not receiving their desired preferences for end of life care. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when: 1. Respiratory care equipment was not stored in a manner to prevent cross contamination (accidently transferring harmful bacteria) for one of five sampled residents (Resident 62). 2. Nasal cannula tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not labeled and dated for three of six sampled residents (Resident 12, Resident 70 and Resident 89). These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of three sampled residents (Resident 1), urine outputs via Foley catheter (thin, flexible tube that drains urine from the bladder into a bag outside the body) were not accurately documented. This failure may have contributed to the hospital transfer to the emergency room for Resident 1. Findings During an interview on 11/19/24 at 11:41 a.m. with Resident 1 (RS1), stated, I was having some pain regarding the catheter, and then I went to the ER [Emergency Room] and the ER pulled the catheter, and then a bunch of urine came out and the pain was relieved . The day I went to the ER there seemed to be a disconnect with the staff, one staff was telling me to drink more water, and another was telling me to stop playing with the catheter . During an interview on 11/21/24 at 12:36 p.m. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders for Lactulose (a medication that helps prevent complications of liver disease and relieves constipation) were adhered to, for one of two sampled residents (Resident 1) when: 1. Resident 1 did not receive a scheduled dose of Lactulose due to a family outing. 2. Nursing staff did not notify Resident 1's physician, when Resident 1 had less than three bowel movements a day, on four separate occasions. This failure placed Resident 1 at risk to have irregular bowel moements and other adverse reactions.

Inspectors wroteBased on interview and record review and, the facility failed to ensure staff accurately assessed and documented a fall risk evaluation for one of two residents (Residents 1). This failure had the potential to result in Resident 1 not receiving appropriate interventions for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly implement infection prevention and control practices according to recognized guidelines when: 1. Personal protective equipment (PPE - gowns, gloves, masks, and face/eye protection to protect body from injury or infection) supplies required during contact with residents placed on Enhanced Standard/Barrier Precautions [ESBP - an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes and involve gown and glove use during high-contact resident care activities] were placed inside the room in close proximity to the residents. 2. A certified nursing assistant (CNA 3) was observed changing bed linen in a resident's room placed on ESBP without appropriate PPE. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote Resident 95's dignity when Resident 95 received assistance with eating, in the dining room in the Alzheimer's unit, 45 minutes before a resident at the same table received his meal, and while six other residents in the small dining room waited for their lunch meal. In addition, Resident 40 was not provided dining in a dignified manner when Resident 40 received assistance with eating in a hallway, while multiple other residents in the same hallway continued to wait 45 minutes for their lunch meal.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written informed consent was secured from one of 25 sampled residents (Resident 61) or from the resident's representative, for a dosage increase of the medication Duloxetine [a psychotropic medication (alters mood, perceptions, and behavior) used to treat depression and anxiety]. This failure violated Resident 61's right to be informed of a change in psychotropic medication regimen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an accurate and effective system for monitoring parameters of nutritional status for one of 6 sampled residents (Resident 43), when: 1. A comprehensive nutrition assessment was incomplete when Resident 43's individual daily calorie, protein and fluid needs were not assessed on admission. 2. A gradual, weight loss goal consisting of twenty-four pounds was documented as non-significant weight loss on Resident 43's admission Nutrition Comprehensive Assessment (NCA) and on the interdisciplinary team (IDT) nutrition care plan (IDTNCP) had not involved the physician to ensure the provider responsible for the care of the patient was guiding the nutrition care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the director of food and nutrition services (Dietary Manager] received consistent and sufficient frequently scheduled consultations from the facility's Registered Dietitian (RD) to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with safe food handling and sanitation (Cross Reference F812), meal distribution (Cross Reference F550) and implementation of therapeutic diets (Cross Reference F803).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the therapeutic diet/menu as planned during lunch trayline (a system of food preparation in which trays move along an assembly line) when: 1. A salt packet was placed on the lunch meal tray for 2 of 25 sampled residents (Resident 53 and Resident 112) who had a physician prescribed Heart Healthy diet order. 2. The Soft, Bite Sized Food (SB6) diet was not followed related to the size of green beans in accordance with the facility's Diet Manual for SB6 diet, for one of 25 sampled residents (Resident 89). This failure had the potential to negatively impact the residents nutritional and/or medical status. In addition, not following the correct size of food for a SB6 diet had the potential to place the resident at an increased risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 43) meal tray card that listed dinner roll as a food dislike was honored when a dinner roll was served on Resident 43's lunch meal plate. Failure to follow a resident's food preferences had the potential to result in decreased meal consumption and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective sanitary practices and safe food handling when: 1. One of two food and nutrition services staff was not following manufacturer's guidelines for contact time related to sanitizing meal delivery carts to ensure they were effectively sanitized. 2. Three of five logged entries on the Cooling Temperature Log indicated TCS foods (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not accurately cooled down to ensure food safety. 3. Dry food ingredients were stored directly in non-food grade trash liners. As a result, residents were placed at an increased risk for developing a food borne illness.