Health inspection·January 19, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy and procedure (P/P), the facility failed to ensure the environment was free of accidents when one of three residents (Resident 1's) wheelchair was not safely maintained. Resident 1's wheelchair left lock was broken. This facility failure resulted in Resident 1's wheelchair sliding backwards and the resident sustaining an assisted fall from the wheelchair. Findings: During a record review of Resident 1's Face Sheet, (a document that gives a patient's information at a quick glance) the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Chronic Kidney Disease (when kidneys cannot filter blood as they should), and Diabetes (too much sugar in the blood). During a review of an assessment form titled, Resident Assessment Instrument (RAI - a document utilized to assess the nursing need of a resident), dated 10/23, the RAI indicated, Definitions . Fall: Unintentional change in position coming to rest on the ground or onto the next lower surface (e.g., onto a bed, chair, or bedside mat), but not as a result of an overwhelming external force. During a record review of Resident 1's Morse Fall Scale (MFS - rapid and simple method of assessing a patient's likelihood of falling), dated 12/2/23, the MFS indicated, Resident 1 was a High Risk for Falling. During a record review of Resident 1's Nursing Progress Note (NPN), dated 12/2/23 at 7:48 a.m., the NPN indicated, while assisting Resident 1 to transfer from bed to wheelchair, Resident 1 slid off the wheelchair to the floor with the wheelchair breaks on. During an interview on 1/3/24 at 10:57 a.m. with Licensed Nurse (LN 1), LN 1 confirmed while Resident 1 was being transferred from the bed to the wheelchair, the wheelchair was locked but the wheelchair slid backwards, and Resident 1 slid to the floor. During an interview on 1/17/24 at 1:21 p.m. with Facility Engineer (FE), the FE confirmed the left side lock on Resident 1's wheelchair was not working, causing the wheelchair to move backwards. During a review of the facility's policy and procedure (P&P) titled, Bio Medical Equipment, dated (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 01/19/2024 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)