Health inspection·August 1, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few matters was to grab her by the arm. Resident 1 was asked if he was temporary separated from Resident 2 after the incident. Resident 1 stated No, I see her (Resident 2) during breakfast, at activities, I see her (Resident 2) all the time . Resident 2's medical record was reviewed on 8/1/24. Record indicated resident's BIMS score was 15. Diagnosis included left side of upper body impaired due to a brain stroke and psychoactive substance abuse. During an interview with Resident 2 on 8/1/24 at 3:03 p.m., resident stated He (Resident 1) grabbed my arm so hard that I was saying aww, aww. During an interview with activities leader (AL) on 8/1/24 at 12:42 p.m., AL confirmed witnessing the alleged abuse incident between the two residents (Resident 1 and 2) on 7/17/24 around 4: 00 p.m., AL stated [Resident 1's name] was on the pathway when [Resident 2's name] was going towards the door to the patio, to go smoke. [Resident 2's name] intentionally charged and ran into [Resident 1's name] wheelchair, running over his feet. It was like [Resident 2's name] said you're in my way so I'm going to run over you . She (Resident 2) did this intentionally. [Resident 1's name] then grabbed her (Resident 2) arm and squeezed it. [Resident 2's name] was saying ouch ouch. I intervened and separated them. I called and reported this to the supervisor [Supervisor's name], she said she will follow up later. Later, I checked on [Resident 1's name] , he said She (Resident 2) ran into me on purpose. During a concurrent review of Resident 2's document titled Activity Dining Room Code of Conduct and interview with the activities director (AD) on 8/1/24 at 12:52 p.m., the AD reported that on 7/12/24 the Code of Conduct rules were reviewed with Resident 2 because resident had been loud, use foul language and disturbing others, in the past. However, on 7/12/24, the resident was out of control, especially, with the use of foul language that necessitated for the AD to review and remind the resident of the rules listed on the Code of Conduct document. During an interview with the nursing supervisor (NS) on 8/1/24 at 2:10 p.m., NS confirmed being notified by activities leader (AL) regarding Resident 1 and Resident 2 alleged abuse incident (altercation) on 7/17/24. NS reported, later, checking on Resident 1. Resident 1 was upset with Resident 2 but with his expressive aphasia it was difficult to understand him and was getting frustrated. Later, NS checked on Resident 2 who was up on the front of the facility, at the time. According to NS, Resident 2 denied being hurt. Therefore, NS did not think this was a resident -to-resident abuse and nothing was done about this. On 7/19/24, Resident 2 reported to nursing staff that on 7/17/24 Resident 1 had grabbed her arm and hurt her. An investigation was initiated on 7/19/24 where details were discovered that on 7/17/24 Resident 2 intentionally ran into Resident 1's wheelchair, running over his feet. Then, Resident 1 grabbed Resident 2's arm and squeezed it. Resident 2 was saying ouch, ouch . NS was asked if on 7/17/24 when she checked on Resident 1 and 2, did she asked residents if there was any physical contact between them or did she asked the details of the incident. NS stated No, I did not . NS was asked if she performed an assessment of both residents on 7/17/24 and documented the assessment in the medical record. NS stated No I did not. I did not document any assessment or incident details etc. I did not write any notes in the residents record. I didn't think I needed to since they were both fine. During a concurrent review of the facility policy titled Prevention of Abuse and interview with the facility manager (FM) on 8/1/24 at 3:45 p.m., the FM acknowledged and confirmed for two days, from 7/17/24 to 7/19/24, the facility did not implemented their policy and procedure related to abuse by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055256 If continuation sheet Page 2 of 3 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 08/01/2024 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)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete one resident to another. FM confirmed on 7/17/24, date of the alleged abuse incident, the facility did not 1. Temporarily separated the residents so they do not interact with each other until investiagtion was completed. 2. Determine the cause for the abuse. 3. Notify the physicians and responsible parties. 4. Closely monitor the residents. 5. Initiate care plan with interventions. 6. Physical assessment of residents involved was not completed with findings documented in the record. Facility did not report alleged abuse incident to CDPH within 24 hours of incident. Furthermore, FM agreed the facility cannot account for Resident 1 and Resident 2 whereabouts and interactions between the two of them from 7/17/24 to 7/19/24, two days from the alleged abuse incident. Event ID: Facility ID: 055256 If continuation sheet Page 3 of 3