Inspection·February 6, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to follow professional food storage standards for labeling food in 1 of 1 walk-in freezer in the facility kitchen. Residents Affected - Few Findings included: An undated facility policy titled Procedure For Refrigerated Storage revealed, 10. Leftovers will be covered, labeled and dated. (See leftover policy section 7.). The policy also revealed, 13. Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. An undated facility policy titled, Food Preparation - Leftover Foods, indicated, Leftover foods are those that have been prepared for a meal and not served. 1. Storage of food B. Label and date. An initial tour of the kitchen was conducted on 02/03/2025 at 8:47 AM with the Food Nutrition Director (FND). During the tour of the facility's walk-in freezer, one clear, gallon-sized freezer bag of fruit slices and one clear, quart-sized freezer bag with a leftover waffle were observed without any description of the contents or the date the products were opened. During an interview on 02/03/2025 at 8:47 AM, the FND stated that they were unsure why the fruit slices and waffle were not labeled or dated. A follow-up tour of the kitchen was conducted on 02/04/2025 at 11:22 AM with the Food Production Supervisor (FPS). During an observation of the walk-in freezer, one clear package containing deli meat slices was observed without any description of the contents or date the product was opened. During an interview on 02/04/2025 at 11:22 AM, the FPS stated that they had forgotten to label and date the package. During an interview on 02/05/2025 at 9:16 AM, Food Service Worker (FSW) #3 stated that, when a food item was opened, they must ensure the package was labeled with the date it was opened, a description of contents, and a best by date. During an interview on 02/05/2025 at 9:23 AM, [NAME] #2 stated they had a sticker they used to label food items. [NAME] #2 stated when a food package was opened, they had to label the item with the date that it was opened, a best by date, and a description of contents. She stated after six days, they had to remove those items and discard any food item that did not have a date. [NAME] #2 further stated it was their responsibility to check for food items that were not labeled and throw them away. (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 02/06/2025 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)