Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lompoc Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple health conditions, including malnutrition and pressure ulcers, experienced repeated significant weight loss. Facility staff did not follow policy to re-weigh after a 5% or greater loss and failed to notify the RD in writing, instead relying on verbal communication. This led to increased weight loss, worsening malnutrition, delayed treatment, and slower healing of pressure sores.
A urinary catheter bag was found lying on the floor next to a resident with multiple health issues, contrary to facility policy requiring catheter bags to be kept off the floor. Additionally, a CNA delivered lunch trays to two residents without providing hand hygiene before meals, in violation of the facility's infection control standards.
A facility failed to ensure a resident's self-administration of medication was approved by the IDT. A rescue inhaler was found in the resident's drawer, which the resident used as a backup when smoking outside. A nurse was unaware of the inhaler's presence and confirmed the resident lacked approval to self-administer medications. Facility policy requires IDT and physician approval for self-administration.
The facility did not keep the survey results binder up-to-date, with the most recent results missing from April 2024 to January 2025. This oversight was acknowledged by the Administrator during an interview, highlighting a lapse in ensuring residents and their families had access to the latest survey findings.
The facility failed to ensure call lights were within reach for two residents, as required by their care plans. Observations revealed that one resident's call light was on the floor, and another's was behind a radio, both out of reach. This oversight could lead to unmet needs and increased fall risk.
The facility failed to follow physician orders for three residents, leading to potential health risks. A resident did not have blood pressure documented before receiving Hydralazine, another was not weighed daily for heart failure monitoring, and a third had no blood pressure readings documented before withholding Lisinopril. The Director of Staff Development confirmed these documentation gaps.
The facility failed to ensure emergency drugs were available when ordered, as the Emergency Drug Supply Kit (E-Kit) was not reordered timely after being opened. An opened E-Kit with red locks was observed, indicating it had been accessed, but the last reorder was documented in August 2024. The facility's policy requires medications used from the E-Kit to be replaced upon the next routine drug order.
Two residents experienced significant medication administration errors. One resident with type 1 diabetes did not receive Insulin Aspart as per the sliding scale, and another resident with multiple conditions did not receive Diltiazem, Metoprolol Tartrate, and Clonidine according to prescribed parameters. The facility's staff failed to follow medication administration procedures, leading to these errors.
The facility failed to label nebulizer medications with opened dates for several residents and did not discard expired test strips, as observed during an interview with the DSD. Unlabeled and undated medication packets, including Albuterol, DuoNeb, and Budesonide, were found in medication carts. Additionally, expired Coaguchek XS PT test strips were not discarded, contrary to the facility's policy.
The facility failed to ensure accurate documentation of POLST in the EMR for three residents. A resident's POLST indicated DNR, but the EMR showed FULL CODE, acknowledged by an LPN. Another resident's POLST also indicated DNR, but the EMR showed FULL CODE, confirmed by the DSD. A third resident's POLST indicated DNR, but the EMR showed FULL CODE, confirmed by an LPN. These discrepancies could affect residents' end-of-life care preferences.
The facility failed to maintain infection control practices for respiratory equipment, as observed in several residents. A nebulizer for a resident was left uncovered, contrary to policy. Additionally, nasal cannula tubing for three residents was not labeled or dated, with some tubing touching the floor. These actions did not comply with the facility's policy requiring weekly changes and labeling, potentially leading to cross-contamination and healthcare-associated infections.
A resident's urine outputs via Foley catheter were not accurately documented, potentially contributing to their transfer to the ER. The resident experienced pain, and upon ER arrival, the catheter was removed, releasing urine and relieving pain. The task for documenting output was not initiated until days after intake was recorded, resulting in no outputs being documented. The facility's policy required documentation of input and output, which was not followed.
Failure to Follow Policy for Significant Weight Loss Notification
Penalty
Summary
The facility failed to follow its own policy regarding the management of significant weight loss in residents. Specifically, for one resident with multiple diagnoses including anemia, malnutrition, dysphagia, and multiple pressure ulcers, the facility did not re-weigh the resident after a weight loss of 5% or more, nor did they immediately notify the Registered Dietitian (RD) in writing as required by their policy. The resident experienced several instances of weight loss exceeding 5% within one-week intervals, but there was no documentation that the RD was notified in writing, and the process for re-weighing and written notification was not followed. Interviews with facility staff confirmed that the current practice was to notify the RD verbally rather than in writing, and that the policy for re-weighing and written notification was not being implemented. The DON acknowledged that the facility's actual process did not match the written policy. As a result, the resident experienced increased weight loss, worsening malnutrition, delayed medical treatment, and slower healing of pressure sores, as directly stated in the report.
Failure to Follow Infection Control Protocols for Catheter Care and Hand Hygiene
Penalty
Summary
A deficiency was identified when a urinary catheter bag belonging to a resident with multiple medical conditions, including a right femur fracture, acute kidney failure, and pressure ulcers, was observed lying on the floor beside the resident's bed. This was confirmed by a licensed nurse, who acknowledged that the catheter bag should not be on the floor, in accordance with the facility's catheter care policy, which requires that catheter tubing and drainage bags be kept off the floor. Additionally, a certified nursing assistant was observed delivering lunch trays to two residents and placing them on their bedside tables without offering hand hygiene before the residents began eating. The CNA acknowledged not providing hand hygiene, which was contrary to the facility's standard precautions policy that requires personnel to assist residents with hand hygiene before meals.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident's self-administration of medication was approved and determined as clinically safe and appropriate by the interdisciplinary team (IDT). During an observation and interview, a rescue inhaler labeled Atrovent HFA was found in the resident's bedside table drawer. The resident stated that the inhaler was brought from home to use as a backup when going outside the facility to smoke. A licensed nurse was unaware of the inhaler's presence and confirmed that the resident did not have approval from the physician and the IDT to self-administer medications. The facility's policy requires that residents may only self-administer medications if the attending physician and the IDT have determined it is safe for them to do so.
Failure to Maintain Current Survey Results Binder
Penalty
Summary
The facility failed to maintain an up-to-date survey results binder accessible to the public, as required by their policy. During an observation and interview with the Administrator at the facility's main entrance, it was found that the most current survey results available in the binder were from March 15, 2024. The binder was missing survey results from April 8, 2024, through January 30, 2025. The Administrator acknowledged that the survey results binder was not current and needed updating. This failure prevented residents, family members, and legal representatives from being informed of the most recent survey results.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to adhere to care plan interventions regarding the accessibility of call lights for two residents, Resident 44 and Resident 17. During an observation, Resident 44's call light was found on the floor, out of reach, which was confirmed by a Certified Nursing Assistant (CNA 2). The care plan for Resident 44 indicated that the call light should be within reach to prevent falls and encourage the resident to use it for assistance. Similarly, Resident 17's call light was observed behind a radio on the nightstand, also out of reach, as confirmed by CNA 1. The care plan for Resident 17 also specified that the call light should be within reach to mitigate fall risks. The facility's policy on comprehensive, person-centered care plans requires that they include measurable objectives and timetables to meet residents' needs. However, the failure to ensure the call lights were accessible for these residents indicates a lapse in following these care plans. This oversight had the potential to leave the needs of Resident 44 and Resident 17 unmet by the staff, as the call lights are a critical tool for residents to request assistance and prevent falls.
Failure to Follow Physician Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to potential health risks. For Resident 93, the staff did not document blood pressure readings before administering Hydralazine, a medication for hypertension, on multiple occasions. This oversight occurred despite a clear physician order to withhold the medication if the systolic blood pressure was below 110. The Director of Staff Development (DSD) confirmed the absence of documentation for these readings, which were required to ensure safe medication administration. Resident 32 was not weighed daily as ordered by the physician for heart failure monitoring, with a specific instruction to notify the physician if there was a weight gain of more than three pounds. The Treatment Administration Record (TAR) lacked documentation of a weight measurement on a specific date, which the DSD acknowledged as a failure to follow the physician's order. Additionally, for Resident 12, the facility did not document blood pressure readings before withholding Lisinopril, another hypertension medication, on several occasions. The DSD noted that the electronic health record system did not require a blood pressure entry if the medication was not administered, leading to gaps in documentation and potential non-compliance with physician orders.
Failure to Reorder Emergency Drug Supply Kit
Penalty
Summary
The facility failed to ensure that emergency drugs were available to residents when ordered, as the Emergency Drug Supply Kit (E-Kit) was not reordered in a timely manner after being opened for use. During an observation and interview with the Director of Staff Development (DSD), it was noted that an opened E-Kit with red locks was present in the medication storage room, indicating it had been accessed by facility staff. The DSD confirmed that the nurse who opened the E-Kit should have reordered it the same day. However, the last documented reorder of the E-Kit was in August 2024, and there was no evidence of it being reordered from the time it was opened until February 2025. The facility's Policy and Procedure on Emergency Medications, dated April 2021, states that medications and supplies used from the emergency kit must be replaced upon the next routine drug order. This failure to reorder the E-Kit as per the policy had the potential to result in emergency drugs not being available during an emergency.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure that medications were administered as directed and ordered for two residents, leading to significant medication errors. Resident 72, who was admitted with type 1 diabetes mellitus and other related conditions, did not receive the prescribed Insulin Aspart according to the sliding scale when their blood sugar levels were within the parameters set by the physician. On multiple occasions, the resident's blood sugar levels were recorded, but the insulin was not administered, and the reason was incorrectly coded as 'no med required - outside parameter.' Interviews with the licensed nurse and the Director of Staff Development confirmed that the insulin sliding scale was not followed, and there was no documentation to justify the non-administration of insulin. Resident 42, who had diagnoses including type 2 diabetes mellitus, COPD, and hypertension, also experienced medication administration errors. The resident was prescribed Diltiazem, Metoprolol Tartrate, and Clonidine, with specific parameters for administration based on blood pressure and heart rate. However, these medications were not administered on several occasions despite the resident's vital signs being within the parameters for administration. Conversely, there were instances where medications were given when they should have been held. The Director of Staff Development acknowledged that the staff did not adhere to the medication administration parameters for this resident. The facility's policy and procedure for administering medications, dated April 2019, stated that medications should be administered in accordance with prescriber orders, including any required time frames. The failure to follow these procedures for both residents resulted in significant medication errors, as confirmed by the review of the Medication Administration Records and interviews with facility staff.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that nebulizer medications were properly labeled with opened dates for two sampled residents and three unsampled residents. During an observation and interview with the Director of Staff Development (DSD), it was noted that several liquid inhalation medication solution packets, including Albuterol, DuoNeb, and Budesonide, were found unlabeled and undated in various medication carts. The facility's policy and procedure for administering medications, dated 2021, requires that the expiration or beyond-use date on the medication label be checked prior to administering and that the date opened be recorded on the container when opening a multi-dose container. Additionally, the facility failed to discard expired test strips, as observed during an interview with the DSD. Three vials of Coaguchek XS PT test strips were found with expired dates in a medication cart. According to the facility's policy and procedure for medication labeling and storage, outdated or deteriorated medications or biologicals should be returned or destroyed as per instructions from the dispensing pharmacy. These failures had the potential to result in residents receiving expired and ineffective medications.
Discrepancies in POLST Documentation in EMR
Penalty
Summary
The facility failed to ensure that the medical records for three residents accurately documented their Physician Orders for Life-Sustaining Treatment (POLST) in the electronic medical record (EMR). For Resident 94, the POLST indicated a Do Not Resuscitate (DNR) status, while the EMR showed a physician order for FULL CODE, indicating a preference for all possible life-saving measures. This discrepancy was acknowledged by a licensed nurse who stated that the EMR should have been updated to reflect the DNR status when the POLST was completed. Similarly, Resident 37's POLST indicated a DNR status, but the EMR contained a physician order for FULL CODE. The Director of Staff Development acknowledged the mismatch and noted that the EMR should have been updated when the POLST was signed. For Resident 17, the POLST indicated a DNR status, but the EMR showed a FULL CODE status. A licensed nurse confirmed that the order for the new DNR status was not updated in the EMR. These discrepancies had the potential to result in the residents not receiving their desired preferences for end-of-life care.
Infection Control Lapses in Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain proper infection control practices concerning respiratory care equipment for several residents. In the case of Resident 62, a nebulizer with an attached T-piece and tubing was observed uncovered on a nightstand, which was acknowledged by a licensed nurse who was unaware of the requirement to cover or enclose the equipment. The facility's policy indicated that nebulizer equipment should be stored in a plastic bag with the resident's name and date after use, which was not followed in this instance. Additionally, the facility did not label and date nasal cannula tubing for three residents, which is a critical step in preventing cross-contamination. Resident 12 was observed with oxygen tubing touching the floor and without a date label, a situation confirmed by a licensed nurse who acknowledged the tubing should not be on the floor and should be dated. Similarly, Resident 89's oxygen tubing was also found touching the floor and undated, and Resident 70's nasal cannula tubing lacked a label. The facility's policy requires oxygen tubing to be changed and labeled every seven days, which was not adhered to in these cases. The infection preventionist confirmed that oxygen nasal cannula tubing and nebulizers are to be changed weekly and labeled with the date and time, a practice that was not consistently implemented. These lapses in infection control practices had the potential to result in cross-contamination and healthcare-associated infections, posing a risk to residents' health and safety.
Failure to Document Catheter Output Leads to ER Transfer
Penalty
Summary
The facility failed to accurately document the urine outputs via Foley catheter for a resident, which may have contributed to the resident's transfer to the emergency room. The resident experienced pain related to the catheter, and upon arrival at the ER, the catheter was removed, releasing a significant amount of urine and relieving the pain. The resident reported a lack of consistent communication from the staff regarding catheter care, with conflicting advice being given. The Director of Staff Development confirmed that the task for documenting catheter output was not initiated until several days after the resident's intake was recorded, resulting in no urine outputs being documented until that time. The resident's physician orders indicated a need for evaluation due to excess hematuria, and the facility's policy required the documentation of input and output, which was not followed. The catheter care plan, created after the deficiency was identified, instructed staff to empty the catheter bag and record the urine amount at the end of each shift.
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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.
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Nursing homes near Lompoc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lompoc Valley Medical Center Comprehensive Care Ce | 1.4 mi | ★★★★★ | 5 | 0 |
| Atterdag Care Center | 19.1 mi | ★★★★★ | 15 | 0 |
| Santa Maria Post Acute | 20.5 mi | ★★★★★ | 4 | 0 |
| Marian Regional Medical Center D/p Snf | 20.8 mi | ★★★★★ | 5 | 0 |
| Valley Oaks Post Acute | 21 mi | ★★★★★ | 11 | 0 |
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