Health inspection·August 22, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure one of 3 sampled residents (Resident 1), was free from physical restraint when Resident 1 was tied to a wheelchair with a scarf. Residents Affected - Few This facility failure has the potential to cause injury to the resident. Findings: During a review of Resident 1's clinical records titled History and Physical on 8/1/23 at 8:20 p.m., indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include hypertension (high blood pressure), ataxia (loss of muscle control in the arms and legs), major depressive disorder, and Dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Further review of clinical records indicated, Resident 1 is non-verbal, wheelchair bound, requires extensive assistance and supervision. During an interview with Licensed Nurse (LN 1) on 8/3/23, at 3:11 p.m., LN 1 explained that Resident 1 was sitting in the middle nursing station when she observed the resident with a leopard print scarf wrapped around her upper chest, and tied in the back, underneath the wheelchair handles, preventing her from moving. During a review of Resident 1's medical record on 8/11/23, at 1:55 p.m., there was no documentation indicating a medical symptom that required the use of a restraint and no physician's order for restraint were noted. Further reviews did not show, there were any nursing notes documenting the use of restraint. During an interview with LN 2 on 8/14/23 at 2:00 p.m., LN 2 acknowledged Resident 1 was restrained with a scarf on her wheelchair on the night of 7/28/23. LN 2 confirmed, the facility was a restraint free facility and there was no order for restraints for Resident 1. During a review of the facility's policy & procedure (P&P) titled, Physical Restraints dated 9/2019, the P&P indicated, 2. Background: All residents have the right to be free from restraint of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff and not required to treat the resident ' s medical symptom . 3. Definitions: a. Physical restraint: Physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to ones ' body .Placing a resident in a chair that prevents from rising. The P&P (continued on next page) 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: 055256 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 055256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Valley Medical Center Comprehensive Care Ce 216 North Third Street 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)