Health inspection·August 18, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few measures health status in nursing home residents), dated 7/07/2023, the MDS indicated, Resident 95 had not had a score entered for BIMS (Brief Interview for Mental Status), and was marked as having severely impaired cognitive skills for daily decision making. An interview with Resident 95 was not possible. During a review of Resident 40's MDS, dated [DATE], Resident 40 had a BIMS of 03 which indicated severe cognitive impairment, therefore, was unable to obtain a resident interview. During an interview on 08/17/23, at 4:18 p.m., with Director of Nursing (DON), the above observations were discussed with DON. DON verified Resident 40's and Resident 95's dignity was not maintained during dining when meals were not provided to all residents at a table, or in very close proximity in the hallway, at the same time. DON acknowledged that was a dignity concern, and DON stated, That is straightforward. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, dated 9/4/17, the P&P indicated, Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Policy Interpretation and Implementation: .Staff shall treat cognitively impaired residents with dignity and sensitivity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 2 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 a written informed consent was secured from one of 25 sampled residents (Resident 61) or from the resident's representative, for a dosage increase of the medication Duloxetine [a psychotropic medication (alters mood, perceptions, and behavior) used to treat depression and anxiety]. Residents Affected - Few This failure violated Resident 61's right to be informed of a change in psychotropic medication regimen. Findings: During a review of Resident 61's admission Record (AR), dated 3/9/22, the AR indicated in part, Resident 61 was a [AGE] year-old, female resident, who was initially admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body), unspecified insomnia (sleeplessness), and unspecified anxiety disorder. During a review of Resident 61's Order Summary Report, dated 8/18/23, the report indicated, the physician order, dated 9/8/22, Duloxetine HCl (hydrochloride) capsule delayed release, sprinkle 60 mg (milligrams), give two capsules by mouth at bedtime for BLE (bilateral lower extremities) neuropathic pain (damage to the nerves causing pain), two capsules = 120 mg, take with food. During a concurrent interview and record review on 8/18/23, at 10:22 a.m., with the Director of Nursing (DON), Resident 61's clinical records were reviewed. The clinical records a Informed Consent for Psychotherapeutic Antidepressants, dated 3/25/22, for a physician order Duloxetine HCl 60 mg (one capsule) for BLE neuropathic pain. No written informed consent was found for Resident 61's most recent Duloxetine order, dated 9/8/23. DON verified Resident 61's new order for Duloxetine, dated 9/8/22, and agreed that a new written informed consent from the resident was required, since there was a medication dosage increase. DON confirmed that a new written informed consent for the Duloxetine dosage increase was not obtained from Resident 61 and acknowledged one should have been secured. During a review of the facility's policy and procedures (P&P) titled, Antipsychotic Medication Use, dated 7/20, the P&P indicated in part, .7) Antipsychotic medications shall generally be used only for the following conditions/diagnoses . e) Mood disorders (e.g., bipolar disorder, depression with psychotic features, and treatment of refractory major depression) . 12) Antipsychotic medications will be used within the dosage guidelines . and informed consent shall be obtained by the physician from the resident of representative, and clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 3 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Provide enough food/fluids to maintain a resident's health. 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 an accurate and effective system for monitoring parameters of nutritional status for one of 6 sampled residents (Resident 43), when: Residents Affected - Few 1. A comprehensive nutrition assessment was incomplete when Resident 43's individual daily calorie, protein and fluid needs were not assessed on admission. 2. A gradual, weight loss goal consisting of twenty-four pounds was documented as non-significant weight loss on Resident 43's admission Nutrition Comprehensive Assessment (NCA) and on the interdisciplinary team (IDT) nutrition care plan (IDTNCP) had not involved the physician to ensure the provider responsible for the care of the patient was guiding the nutrition care plan. The NCA and/or IDTNCP lacked documentation to ensure communication of risks/benefits of weight loss for the [AGE] year old resident with dementia occurred with Resident 43's responsible party (RP) to ensure informed decision, when weight loss was not in accordance with standards of practice for nutrition care for the elderly. 3. Resident 43 had lost significant weight, the facility IDT developed an IDT Nutrition Care Plan (IDTNCP) to address unplanned/unexpected weight loss, in which time another IDTNCP, developed by the Registered Dietitian (RD), was concurrently in place that indicated gradual weight loss was the goal. As a result, there was nursing staff confusion as to the goal for nutrition care for Resident 43. Contradictory and unclear weight goal communication to IDT members had the potential to cause delays in assessing, planning and implementing nutrition interventions in a timely manner to address weight loss. Facility failure to involve the physician, responsible for the care of Resident 43, in decision making related to a weight loss goal of twenty-four pounds from the weight at admission in an [AGE] year old resident had the potential to promote loss of lean body mass (consists of your bones, ligaments, tendons, internal organs and muscles) that has multiple negative health implications. Findings: 1. During a concurrent interview and record review on 08/16/23 at 09:49 a.m., with RD, Resident 43's NCA, dated 10/30/22 was reviewed. The NCA form under the heading of Estimated Nutritional Requirements was blank for estimated caloric, protein and fluid needs for Resident 43. The NCA form indicated, Obtain height and weight in order to complete assessment . RD stated, Resident 43 was re-admitted to the facility on [DATE], and nursing staff had not taken Resident 43's height and weight that was required to be able to assess the resident's daily calorie, protein and fluid needs. RD stated, she usually circles back to complete the nutrition assessment once admission height and weight was obtained, but it was missed. RD verified the admission comprehensive nutrition assessment was incomplete. During a concurrent interview and record review on 08/17/23 at 10:21 a.m., with Licensed Nurse (LN) 1, LN 1 reviewed Resident 43's electronic health record (EHR), and LN 1 stated, Resident 43's admission weight was documented on 10/31/22 by nursing staff. During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated June 16, 2016, the P&P indicated, Procedure - Weights: .Weight will be obtained upon admission . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 4 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 7/01/20, the P&P indicated, The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: a. Nursing: .Current height and weight .Dietitian: An estimate of calorie, protein, nutrient and fluid needs; Whether the resident's current intake is adequate to meet his or her nutritional needs . Residents Affected - Few 2. During a concurrent interview and record review on 08/16/23 at 09:49 a.m., with Registered Dietitian (RD), Resident 43's NCA, dated 10/30/22 was reviewed. The NCA indicated, Past Medical History .Type 2 diabetes mellitus, Alzheimer's disease, .dementia ., Goal: The resident will have gradual, non-significant (5% [loss of body weight] x 30 days and 10% x 180 days) weight loss towards daughter's goal of 160 lbs [pounds], .The resident has nutritional problem: Overweight related to sedentary lifestyle and excess energy intake as evidenced by daughter's report of significant weight gain, approach: Diet Order: Consistent Carb [carbohydrate] diet [for diabetes] .Offer snack at HS [bedtime] .UBW [usual body weight] 190 [lbs], .BLE [Bilateral Lower Extremity ;in/on both legs] + 1 non pit [occurs when excess fluid builds up in the body causing swelling]. per 10/25/22 Nrsg [nursing] Admit Eval [evaluation] . The NCA documentation included Resident 43 had four different DTI [deep tissue injury pressure ulcers] per 10/27/22 weekly documentation for Pressure Sore (done by nursing) .'spoke with daughter [name of daughter] who was visiting resident .Daughter advised of resident's 10/5/2020 weight (156.8 lbs) with daughter replying 'Yes, she has gained some weight and now weighs 190 lbs. The (chronic) swelling to her legs hasn't helped. It would be better for her to lose weight, maybe weigh 160 lbs. The RD was asked if weight loss was in the best interest for Resident 43, and RD stated, Weight loss may be desirable to possibly improve medical conditions, such as her diabetes. During a review of HHS (Health and Human Services) Public Access, titled Excessive Body Weight in Older Adults: Concerns and Recommendations, dated 8/1/2015, indicated, Obese, 80+ years and/or with complicating circumstances: There are essentially no studies of obesity reduction in adults 80 year of age or older. In these individuals, we would therefore advocate for weight maintenance with an emphasis on a healthy diet and exercise as tolerated. This would also be the case for any older adult with a terminal illness, those with severe chronic medical conditions, and persons with moderate to severe dementia. (HHS Public Access Author manuscript; Clin Geriatr Med. Author manuscript; available in PMC 2015 August 01) During a review of Resident 43's History and Physical (H&P), dated 10/26/22, the H&P indicated, .comes in [condition of resident when admitted to the facility] generalized weakness, demented, and unable to care for herself. Patient is brought in for rehabilitation .Extremities: No edema .pressure ulcer present on admission. Continue wound care .Generalized weakness. Patient will need physical therapy . During a concurrent interview and record review on 08/16/23 at 09:55 a.m., with RD, Resident 43's NCA, dated 10/30/22 was reviewed. RD stated, it was the resident's daughter (Responsible Party; RP) who set the goal of 160 lbs so she honored the RP's request. RD was asked for her professional expertise as to whether weight loss for an elderly resident with dementia and limited ability to exercise was within geriatric nutrition standards of practice, and RD stated, Well the daughter wanted it and so I have to honor that. RD then stated, significant weight loss in elderly residents was not advised per standards of practice because it could promote a loss of lean body mass [lean body mass consists of your bones, ligaments, tendons, internal organs and muscles]. RD stated, there was no documentation related to communication with RP of risks and/or reasons why RP's weight loss goal was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 5 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supported by standards of practice to ensure RP was making an informed choice. RD reviewed Resident 43's EHR, and RD stated, she documented a weight change note on 6/14/23 which included the daughter has remarked the weight loss is desirable and anticipated. During a review of an IDT note, dated 6/16/2023, the IDT note indicated, IDT met to review significant weight loss of 18.6 lbs. x [within] 6 months. Current weight is 164.2 lbs. Weight loss is unplanned and r/t [related to] reduced PO (food eaten by mouth) intake secondary to dementia. Daughter has remarked that weight loss is desirable & anticipated, as well as progression of dementia. Resident is eating 0-100 [percent of meals], primarily 0-25%, of meals, 0-100% of SF [sugar free] house supplement [health shake to increase calorie and protein intake] 4 oz [ounces] @ [at] lunch & dinner, 0-100% of Med Pass 2.0 [an oral liquid nutrition supplement to increase calorie and protein intake] 60 ml [millimeters; a unit of measurement] BID [two times a day] and is offered HS [bedtime] snack. RD has no recommendaitons at this time. During a concurrent interview and record review on 08/16/23, at 10:00 a.m., the RD stated, she had developed the IDTNCP, dated as initiated on 10/30/22, Revision on: 5/11/2023, Target Date: 10/15/2023, the IDTNCP indicated, Goal: The resident will have gradual, non-significant (<5% x 30 days and <10% x 180 days) weight loss towards daughter's goal of 160 lbs ., Approaches/Tasks: Diet Order: Consistent Carb diet .Offer snack at HS, SF House supplement, 4 oz @ breakfast and lunch, Med Pass 2.0 60 mL twice daily .Revision on 7/22/2023. During a review of Resident 43's Weights and Vitals Summary, effective date range 10/25/22 - 08/16/2023, Resident 43 weighed 184.2 lbs on 10/31/2022, and weighed 157.8 lbs on 08/15/2023 which was a loss of 13% of Resident 43's body weight in ten months. During a review of National Library of Medicine, an article titled Weight Loss - Unintentional (WL), WL, dated 2/2/2023, indicated, When to Contact a Medical Professional; You have lost more than 10 pounds (4.5 kilograms) or 5% of your normal body weight over 6 to 12 months or less, and you do not know the reason. (https://medlineplus.gov/ency/article/003107.htm) During a review of National Library of Medicine, an article titled An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, indicated, Weight loss of 4% to 5% or more of body weight within 1 year, or 10% or more over 5 to 10 years or longer, is associated with increased mortality or morbidity or both. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/) During a review of Resident 43's Weights and Vitals Summary, effective date range 10/25/22 - 08/16/2023, Resident 43 weighed 184.2 lbs on 10/31/2022, and weighed 157.8 lbs on 08/15/2023 which was a loss of 13% of Resident 43's body weight in ten months. During a concurrent interview and record review on 08/16/23 at 10:08 a.m., with RD, RD was asked if the physician was aware the facility documented a goal weight of 160 lbs, and RD stated, Probably not. RD stated, she did not coordinate the goal of weight loss with the doctor and acknowledged the doctor was responsible for the care of the resident and needed to be involved in that. RD verified there was not a doctor's order to direct a physician-prescribed weight-loss regimen. RD stated, she did not know whose responsibility it was to speak with the doctor to obtain orders and coordinate for a planned weight loss. During a concurrent interview and record review on 08/17/23 at 10:43 a.m., with Director of Nursing (DON), DON reviewed Resident 43's IDTNCP, dated 10/30/22, that documented gradual weight loss toward's 160 lbs as the goal. DON verified there was no documentation in the EHR to indicate Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 6 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Level of Harm - Minimal harm or potential for actual harm 43's physician was involved with establishing a weight goal of 160 lbs. DON stated, she would have expected the RD to communicate with Resident 43's physician relating to a 24 lb weight loss goal since the RD was the one who developed the IDTNCP. The DON verified that risks/benefits and nutrition standards of practice should have been documented discussions with the RP for an informed decision/choice, and was not. Residents Affected - Few During a review of Resident 43's physician Progress Note, dated 11/05/2022 through 07/29/2023, there was no documentation related to Resident 43 having physician direction for weight loss and/or for Resident 43 to have a weight loss goal to 160 lbs. During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team, dated 07/01/2020, the P&P indicated, It is the policy of this facility that the Care Planning/Interdisciplinary Team will be responsible for the development of an individualized comprehensive care plan for each resident ., The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; .The Director of Nursing (as applicable); The Charge Nurse responsible for resident care .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . During a review of the facility's P&P titled, Prevention of Pressure Injuries, dated 2001, the P & P indicated, The purpose of this procedure is to provide information regarding .interventions for specific risk factors .Nutrition: 5. Monitor the resident for weight loss and intake of food and fluids. 6. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan . During a concurrent interview and record review on 08/16/23 at 09:49 a.m., with RD, Resident 43's NCA, dated 10/30/22 was reviewed. TheNCA indicated, Nutritional Intervention .SF Prostat [nutrition supplement to increase protein] related to wound healing. RD stated, the facility did not take action to actively help Resident 43 with weight loss and RD stated, we [the facility] did provide multiple nutrition interventions for increased calories and protein. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, .The comprehensive, person-centered care plan: .c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions . During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 7/01/20, the P&P indicated, Policy: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition .Cognitive or functional decline .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications . According to the American Academy of Family Physician journal, indicated Elderly patients with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 7 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) According to the American Academy of Family Physician journal, indicated Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) According to the Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), indicated Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost. (Journal of the American Dietetic Association, October 2010/Volume 110, Number 10). 3. During a concurrent interview and record review on 08/16/23, at 10:00 a.m., the RD stated, she had developed the IDTNCP,dated as initiated on 10/30/22, Revision on: 5/11/2023, Target Date: 10/15/2023, the IDTNCP indicated, Goal: The resident will have gradual, non-significant (<5% x 30 days and <10% x 180 days) weight loss towards daughter's goal of 160 lbs ., Approaches/Tasks: Diet Order: Consistent Carb diet .Offer snack at HS, SF House supplement, 4 oz @ breakfast and lunch, Med Pass 2.0 60 mL twice daily .Revision on 7/22/2023. During a concurrent interview and record review on 08/17/23, at 10:08 a.m., with Licensed Nurse (LN) 1, LN 1 was asked what the facility's nutrition plan of care was related to Resident 43's weight. LN 1 reviewed Resident 43's IDT Care Plans in the electronic health record (EHR), and LN 1 stated she saw two IDT Nutrition Care plans that were both active, current care plans that both had a target date of completion or review on 10/15/23. LN 1 stated, it's not clear what the weight goal was from the IDT Nutrition Care plans because they conflicted each other. LN 1 stated one was for a planned gradual weight loss towards daughter's goal of 160 lbs and one was developed to address unplanned/unexpected weight loss with a goal of returning to baseline range lbs by review date. LN 1 stated, she did not know what specific weight was meant by baseline range lbs, and LN 1 verified, it would be difficult to monitor, and know when to re-evaluate the effectiveness of care plans with unclear, conflicting care plans were in place. During a concurrent interview and record review on 08/17/23, at 10:38 a.m., with Director of Nursing (DON), Resident 43's IDTNCP, dated as initiated on 10/30/22, Revision on: 5/11/2023, Target Date: 10/15/2023, the IDTNCP indicated, Goal: The resident will have gradual, non-significant (<5% x 30 days and <10% x 180 days) weight loss towards daughter's goal of 160 lbs ., was reviewed. Resident 43's other IDTNCP, dated as initiated on 2/17/23, revision on 5/11/2023, target date: 10/15/23 was reviewed. The IDTNCP indicated, Problem: Unplanned/unexpected weight loss r/t [related to] poor food intake; Goal: The resident's weight will return to baseline range lbs by review date. DON verified both IDTNCP were active, and currently in place. DON verified the two IDTNCP care plans were contradictory and unclear. DON was asked to clarify the goal of resident's weight will return to baseline range lbs, and DON stated, the baseline weight was 160 lbs. During a concurrent interview and record review on 08/17/23, at 10:45 a.m., with DON, Resident 43's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 8 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Weights and Vitals Summary was reviewed. Resident 43 weighed 184.2 lbs on 10/31/22 and weighed 174.6 lbs on 2/12/23. DON verified the facility provided nutrition interventions (SF Health Shake 4 oz. lunch and dinner) to address Resident 43's weight loss when Resident 43 weighed 174.6 lbs, and added an additional nutrition intervention (Med Pass 2.0 60 mL two times a day) when Resident 43 weighed 164.9 lbs. DON verified the facility was concerned about Resident 43's weight loss and acknowledged that a baseline range lbs goal weight of 160 lbs did not make sense, when the facility was concerned when Resident lost ten pounds from 184 lbs to 174.6 lbs, therefore provided a nutrition supplement. DON verified the baseline range lbs goal was not specifically specified and was unclear and ineffective communication to the IDT. DON stated, the IDTNCP indicating planned gradual weight was developed by the RD on 10/30/22, and the IDTNCP to address unplanned weight loss was developed on 2/17/23, as a result of the IDT wt variance committee, dated 2/17/2023. DON verified the facility had two IDTNCP care plans in place that were contradictory, unclear and not accurate communication to the IDT which could impede effective monitoring and evaluating parameters of nutritional status for Resident 43. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; when the desired outcome is not met . During a review of the facility's policy and procedure (P&P) titled, Care Planning- Interdisciplinary Team, dated 07/01/2020, the P&P indicated, It is the policy of this facility that the Care Planning/Interdisciplinary Team will be responsible for the development of an individualized comprehensive care plan for each resident ., The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; .The Director of Nursing (as applicable); The Charge Nurse responsible for resident care .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated June 16, 2016, the P&P indicated, Procedure - Weight Management Committee .The committee will review and update the resident's care plan as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 9 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure the director of food and nutrition services (Dietary Manager] received consistent and sufficient frequently scheduled consultations from the facility's Registered Dietitian (RD) to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with safe food handling and sanitation (Cross Reference F812), meal distribution (Cross Reference F550) and implementation of therapeutic diets (Cross Reference F803). Findings: During a concurrent observation and interview on 08/15/23, at 10:06 a.m., with Dietary Aide (DA) 1, in the kitchen, DA 1 was observed using a spray bottle to spray a solution onto a meal delivery cart and proceeded to immediately wipe off the solution with a white terry cloth towel. During an interview on 08/15/23, at 10:09 a.m., with Dietary Manager (DM) and DA 1, DA 1 verified he did spray the sanitizing solution onto the meal delivery cart and immediately wiped off with a cloth. DM and DA 1 was asked what the manufacturer's contact time was for the product in order to effectively sanitize. DM went to a closet located near the dish machine washing area and reviewed a poster titled SMARTPOWER Sink & Surface Cleaner Sanitizer provided by the manufacturer of the sanitizer. DM stated, the sanitizing solution should remain wet for 60 seconds. DM verified the manufacturer's directions to ensure effective sanitizing of the meal delivery cart had not been followed. DM stated, the specific sanitizing product had been in use in the kitchen for about a month. During a concurrent interview and record review on 08/16/23 at 3:32 p.m., with Dietary Manager (DM), DM reviewed the logged entry, dated 9/19/22, on the facility's Food & Nutrition: 2-Stage Cooling Temperature Log (CL), and DM stated, it was his initial's indicating he cooled down the fortified soup that day. DM reviewed the logged entry for 9/19/22 and stated the CL had not reflected correct and safe cool down procedures when the temperature of the fortified soup was 99 degrees F, after the 2-hour initial cool down. DM reviewed the CL, dated 9/3/22 through 6/27/23, and verified 3 of 5 logged entries on the CL was not done safely when the 2-hour initial cool temperatures were not down to 70 degrees F or less, yet staff continued the cool down process. DM verified the Corrective Action/Notification column located on the CL was blank. During a review of the facility's CL, the CL reflected unsafe cool down practices had occurred since at least September 2022 (11 months), without prompt corrective action and resolution to ensure the health and safety of residents. During an interview on 08/16/22, at 02:59 p.m., with RD, RD stated, she tried to do a food safety and sanitation audit over the foodservice operations once a month but has missed several months. RD stated, she did a recent audit and will provide a copy, and repeated, previous to that it had been several months since she had completed one. RD stated, it was the DM who was responsible for the day- to- day foodservice operations. RD stated, there was not a formal, designated scheduled time set aside to ensure the monthly food safety and sanitation audit was completed, and it just depended if she had the time as her nutrition assessments were priority. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 10 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with DM on 08/17/23, at 11:34 a.m., DM stated, he was the Certified Dietary Manager and responsible for the day-to-day foodservice operation. DM stated, the RD audit over food safety and sanitation should be done once a month. DM stated, the RD has completed them the last couple of months and verified they were not consistently completed once a month. DM was requested to provide copies of the audits that have been done the past couple of months by RD, as none had been received yet from the facility and/or RD. DM provided one kitchen audit that was titled Dietary Services - Kitchen Sanitation, dated 8/5/2023, in which two out of four pages of the audit were provided, page 2 and page 4 were missing, and page 1 was blank. During a concurrent observation and interview on 08/16/23, at 11:30 a.m., of the lunch trayline meal service in the kitchen, a salt packet was observed on Resident 53's lunch meal tray, and DA 1 was asked if a Heart Healthy diet gets a salt packet. DA 1 stated, Yes. During a concurrent interview and record review on 08/16/23 at 12:23 p.m., with DM, DM was asked if a heart healthy diet was to receive a salt packet. DM reviewed the therapeutic menu extension spreadsheet and verified there was no direction to dietary staff to not provide a salt packet for heart healthy diet orders. During an interview on 08/16/23, at 01:07 p.m., with DM, DM stated, he called his corporate office and spoke with the person who developed the heart healthy menu, and who had conducted a nutrient analysis for the Heart Healthy menus, and was told a heart healthy diet should not get a salt packet provided on the meal tray. During an interview on 08/16/23, at 02:59 p.m., with RD, RD stated, a salt packet should not be provided with a therapeutic Heart Healthy diet order. RD reviewed therapeutic spreadsheet for Heart Healthy diet and verified direction to not provide a salt packet was not readily available for dietary staff. RD verified DM and dietary staff should have had the system and clear guidance provided to them for them to follow, and RD stated, It's just more for me to do. RD stated, she did review and sign off on the facility's menus, including therapeutic diets, and facility's diet manual. During a review of Resident 53's Order Listing Report (OLR), the OLR indicated, Heart Healthy (Low Fat, Low Chol [cholesterol], 2-3 GM Na+ [sodium]) diet, dated 7/17/2023. During a review of the facility's nutrient analysis for the facility's heart healthy menu, one day (Thursday) provided 4,377 mg of sodium in a day. During a review of the titled Dietary Services - Kitchen Sanitation, dated 8/5/2023, under Menu And Meal Planning, the column titled Menu Guide, Diet and P & P Manuals were marked as Yes (no concerns identified). During a concurrent observation and interview on 08/16/23, at 12:27 p.m., of the lunch trayline meal service in the kitchen, [NAME] 1 was observed to plate Resident 89's lunch meal to include green beans. Resident 89's meal tray card indicated Texture: Soft & Bite-Sized SB6. [NAME] 1 was asked what size of food was meant by Bite-Sized. [NAME] 1 reviewed the therapeutic menu spreadsheet for SB6 diet and pointed to the Green Beans-chopped as indicated on the spreadsheet, and [NAME] 1 stated, Chopped. [NAME] 1 stated he was not trained on a specific size to chop food for SB6 diet. During a concurrent observation and interview on 08/16/23, at 12:30 p.m., of the lunch trayline meal service in the kitchen, Dietary Manager (DM) observed the green beans on Resident 89's plate and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 11 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0801 Level of Harm - Minimal harm or potential for actual harm reviewed the therapeutic menu spreadsheet, and DM stated, he did not know what size constituted chopped for SB6 diet. DM was requested to refer to the facility's Diet Manual to review SB6 diet and was informed IDDSI [International Dysphagia [difficulty in swallowing] Diet Standardisation], was standardized and SB6 diet indicated for 1.5 cm [centimeters; a unit of measurement] x 1.5 cm sized food. [NAME] 1 and DM both verified the green beans were larger in size than that. Residents Affected - Few During an interview on 08/16/23, at 03:05 p.m., with RD, the observation of the SB6 diet during trayline was shared with RD. RD stated, the ST (Speech Therapist) provided training on implementing the IDDSI diet system because she did not have time to assist with implementation of the new therapeutic diet orders at the facility, and referred any questions about the SB6 diet to the ST. RD stated, she told the DM to have a tray checker position [DA 1] and had provided verbal guidance over trayline from time to time but acknowledged it was not a formal structure with scheduled time to ensure that task was consistently accomplished. RD was asked if she could provide any documented in-services or training's she had provided to dietary staff, and RD stated, no, because she needed the time she had at the facility, three days a week, to do clinical nutrition care. RD stated, she did not attend QAPI meetings (quality assurance performance improvement) because QAPI meetings were not held on the days she worked at the facility, plus it would take time away from her conducting resident nutrition assessments. During a concurrent observation and interview on 08/17/23, at 08:49 a.m., with ST, ST observed a picture that was taken of Resident 89's lunch meal plate that [NAME] 1 and DM had observed, and ST stated, the green beans were not appropriate size for SB6 diet. ST verified the green been pieces were too large for SB6 diet. ST stated, she trained the nursing staff at the facility on the new IDDSI therapeutic diets, and she thought a dietary manager from corporate instructed the dietary staff. ST verified the RD told her she did not have time to collaborate with ST to implement the new system for IDDSI therapeutic diet orders/menus at the facility. During a review of the RD's job description titled Dietitian, dated 9/25/2019, the job description indicated, The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are being provided on a daily basis and that the food services department is maintained in a clean, safe, and sanitary manner .Duties and Responsibilities .Assume the administrative authority, responsibility and accountability of directing the Food Services Department., Plan, develop, organize, implement, evaluate, and direct our facility's Food Services Department, its programs and activities, Coordinate food service activities with other related departments (i.e., Nursing, Environmental, Activities, Social Services, etc.) as necessary ., Assist the food services staff in the development and use of departmental procedures governing food service activities, equipment, supplies, etc., .Develop, implement, and maintain an ongoing quality assurance program for the Food Services Department, .Visit residents periodically to evaluate the quality of meals served .meal times ., Assist in planning regular and special diet menus as prescribed by the attending physician, .Assist the Director of Food Services in planning menus ., Review therapeutic and regular diet plans and menus to assure they are in compliance wit the physician's orders, Meet with Administration, medical and nursing staff, as well as other related departments, in planning food service programs and activities, .Meet with food service personnel, on a regularly scheduled basis, and solicit advice from staff concerning the operation of the Food Services Department. Assist in identifying and correcting problem areas, and/or the improvement of services, .Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 12 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0801 Level of Harm - Minimal harm or potential for actual harm to ensure a well-educated food services department ., Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner, .Ensure that all food service personnel follow established departmental policies and procedures . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 13 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the therapeutic diet/menu as planned during lunch trayline (a system of food preparation in which trays move along an assembly line) when: 1. A salt packet was placed on the lunch meal tray for 2 of 25 sampled residents (Resident 53 and Resident 112) who had a physician prescribed Heart Healthy diet order. 2. The Soft, Bite Sized Food (SB6) diet was not followed related to the size of green beans in accordance with the facility's Diet Manual for SB6 diet, for one of 25 sampled residents (Resident 89). This failure had the potential to negatively impact the residents nutritional and/or medical status. In addition, not following the correct size of food for a SB6 diet had the potential to place the resident at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 08/16/23, at 11:30 a.m., of the lunch trayline meal service in the kitchen, Resident 53's meal tray was observed placed on the meal delivery cart by dietary aid (DA) 1 after checking the meal tray for accuracy. Resident 53's meal tray card indicated Special Diets: Heart Healthy . A salt packet was observed on Resident 53's lunch meal tray, and DA 1 was asked if a Heart Healthy diet gets a salt packet. DA 1 stated, Yes. Dietary Aide (DA) 2, who placed the salt packet on Resident 53's lunch meal tray, and DA 1 both stated they had never been told to not serve a salt packet for a heart healthy diet. During a concurrent observation and interview on 08/16/23, at 11:54 a.m., of the lunch trayline meal service in the kitchen, Resident 112's lunch meal tray was observed to have two salt packets on his lunch meal tray. Resident 112's lunch meal card indicated Special Diets: Heart Healthy . DA 2 stated, two packets of salt was placed in error because they [the salt packets] stuck together. DA 2 stated, there should only be one salt packet on the heart healthy meal tray. During a concurrent interview and record review on 08/16/23 at 12:23 p.m., with Dietary Manager (DM), DM was asked if a heart healthy diet was to receive a salt packet. DM reviewed the therapeutic menu extension spreadsheet and verified there was no direction to dietary staff to not provide a salt packet for heart healthy diet orders. DM stated, a Heart Healthy diet was a 2 gram sodium diet (a diet that is limited to 2,000 milligrams [a unit of measurement] of salt in a day). During an interview on 08/16/23, at 01:07 p.m., with DM, DM stated, he called his corporate office and spoke with the person who developed the heart healthy menu, and who had conducted a nutrient analysis for the Heart Healthy menus, and was told a heart healthy diet should not get a salt packet provided on the meal tray. During an interview on 08/16/23, at 02:59 p.m., with Registered Dietitian (RD), RD stated, a salt packet should not be provided with a therapeutic Heart Healthy diet order. During a review of the facility's Diet Manual for 2 Gram Sodium Diet [provided by DM when asked for a copy of the Heart Healthy diet from the facility's Diet Manual], last approved by the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 14 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 01/17/2023, 2 gm sodium diet indicated, Indications and Rationale: This diet may be indicated for residents with the following conditions: Cardiovascular disorders (heart failure or hypertension) ., .the elimination of iodized salt [salt packets] ., provides .a restriction of 2 grams (2,000 mg) of Sodium . During a review of Resident 53's Order Listing Report (OLR), the OLR indicated, Heart Healthy (Low Fat, Low Chol [cholesterol], 2-3 GM Na+ [sodium]) diet, dated 7/17/2023. During a review of Resident 112's OLR, the OLR indicated, Heart Healthy (Low Fat, Low Chol [cholesterol], 2-3 GM Na+ [sodium]) diet, dated 8/07/2023. During a review of the facility's nutrient analysis for the facility's heart healthy menu, one day (Thursday) provided 4,377 mg of sodium in a day. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2017, the P&P indicated, Regular and therapeutic menus will be written by the facility's food and nutrition professional in accordance with the facility's approved diet manual or purchased from an approved vendor. The registered dietitian nutritionist (RDN) or designee will approve all menus. During a review of the facility's policy and procedure (P&P) titled, Diet/Nutrition Care Manual, dated 2017, the P & P indicated, Policy: The diet/nutrition care manual used in the facility will reflect current nutritional knowledge and recommendations, and will be approved for use by the medical staff . 2. During a concurrent observation and interview on 08/16/23, at 12:27 p.m., of the lunch trayline meal service in the kitchen, [NAME] 1 was observed to plate Resident 89's lunch meal to include green beans. Resident 89's meal tray card indicated Texture: Soft & Bite-Sized SB6. [NAME] 1 was asked what size of food was meant by Bite-Sized. [NAME] 1 reviewed the therapeutic menu spreadsheet for SB6 diet and pointed to the Green Beans-chopped as indicated on the spreadsheet, and [NAME] 1 stated, Chopped. [NAME] 1 stated he was not trained on a specific size to chop food for SB6 diet. During a concurrent observation and interview on 08/16/23, at 12:30 p.m., of the lunch trayline meal service in the kitchen, Dietary Manager (DM) observed the green beans on Resident 89's plate and reviewed the therapeutic menu spreadsheet, and DM stated, he did not know what size constituted chopped for SB 6 diet. DM was requested to refer to the facility's Diet Manual to review SB6 diet and was informed IDDSI [International Dysphagia [difficulty in swallowing] Diet Standardisation], was standardized and SB 6 diet indicated for 1.5 cm [centimeters; a unit of measurement] x 1.5 cm sized food. [NAME] 1 and DM both verified the green beans were larger in size than that. During a concurrent observation and interview on 08/17/23, at 08:49 a.m., with Speech Therapist (ST), ST observed a picture that was taken of Resident 89's lunch meal plate that [NAME] 1 and DM had observed, and ST stated, the green beans were not appropriate size for SB6 diet. ST verified the green been pieces were too large for SB6 diet. During a review of Resident 89's Order Listing Report (OLR), the OLR indicated, Regular diet Soft & Bite-Sized texture . During a review of Resident 89's Speech Therapy Treatment Encounter (STTE), dated 10/19/22, the STTE indicated, Pt [patient] presents with oropharyngeal dysphagia [swallowing problems occurring in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 15 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0803 the mouth and/or the throat] . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Diet Manual for the Soft and Bite Size (SB6) diet, last approved by the facility on 01/17/2023, the SB6 diet indicated, Indications and Rationale: The IDDSI Soft and Bite Size (Level 6 .) diet is indicated for the resident who has difficulty chewing or swallowing .Food pieces are to be no larger than 15 mm [millimeter] length by 15 mm width (adults). Refer to a speech-language pathologist [ST] as needed ., Vegetables are to be cooked to a fork-mashable (soft) texture and no > [no greater than] 15 mm pieces . Residents Affected - Few During a review of IDDS FAQ (frequently asked questions), IDDSI FAQ indicated, All foods need to meet the particle size requirements for Level 6 Soft & Bite-sized. The relationship between particle size and risk of asphyxiation [the state or process of being deprived of oxygen] has been identified in the literature ([NAME] & [NAME], 2006; [NAME] et al., 2014) .In order to avoid asphyxiation, particles should be small enough to pass through rather than block the trachea [the windpipe]. The average tracheal size for adult males is 22mm and for adult females is 17 mm ([NAME] et al., 1996). Particle sizes of 15 mm (i.e. 1.5cm) size are therefore more likely to pass through the trachea, than block it. (https://iddsi.org/FAQ/Foods) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 16 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 43) meal tray card that listed dinner roll as a food dislike was honored when a dinner roll was served on Resident 43's lunch meal plate. Failure to follow a resident's food preferences had the potential to result in decreased meal consumption and weight loss. Findings: During a concurrent observation and interview on 08/15/23, at 01:02 p.m., with Certified Nursing Assistant (CNA) 4, in Resident 43's room, CNA 4 observed a dinner roll on Resident 43's lunch meal plate and verified dinner rolls was listed as a food dislike on Resident 43's lunch meal card. CNA 4 stated the dinner roll should not have been served. Resident 43 stated she does not like dinner rolls and when the list of dislikes listed on her meal tray card was reviewed with her, Resident 43 pointed to her dinner roll, and stated, Imagine that. During a review of the facility's planned lunch menu for 8/15/23, the lunch meal included Dinner Roll . During a review of the facility's policy and procedure (P&P) titled, Meal Identification and Preference Cards/Tickets, dated 2017, the P&P indicated, Policy: A meal identification (ID) and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences ., meal ID card/ticket should include the name of the individual, diet order, beverage preferences, food dislikes and any other applicable diet information .Meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 17 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 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 record review, the facility failed to ensure effective sanitary practices and safe food handling when: Residents Affected - Few 1. One of two food and nutrition services staff was not following manufacturer's guidelines for contact time related to sanitizing meal delivery carts to ensure they were effectively sanitized. 2. Three of five logged entries on the Cooling Temperature Log indicated TCS foods (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were not accurately cooled down to ensure food safety. 3. Dry food ingredients were stored directly in non-food grade trash liners. As a result, residents were placed at an increased risk for developing a food borne illness. Findings: 1. During a concurrent observation and interview on 08/15/23, at 10:06 a.m., with Dietary Aide (DA) 1, in the kitchen, DA 1 was observed using a spray bottle to spray a solution onto a meal delivery cart and proceeded to immediately wipe off the solution with a white terry cloth towel. DA 1 was observed three times spraying different areas of the meal delivery cart with the solution located in the spray bottle, and each time was observed to immediately use a white terry cloth towel to wipe off the solution. DA 1 stated, he was sanitizing the meal delivery cart that was returned to the kitchen that had contained dirty breakfast meal trays from residents. DA 1 showed the spray bottle was filled with a sanitizing solution called Sink and Surface Sanitizer. During an interview on 08/15/23, at 10:09 a.m., with Dietary Manager (DM) and DA 1, DA 1 verified he did spray the sanitizing solution onto the meal delivery cart and immediately wiped off with a cloth. DM and DA 1 was asked what the manufacturer's contact time was for the product in order to effectively sanitize. DM went to a closet located near the dish machine washing area and reviewed a poster titled SMARTPOWER Sink & Surface Cleaner Sanitizer provided by the manufacturer of the sanitizer. DM stated, the sanitizing solution should remain wet for 60 seconds. DM verified the manufacturer's directions to ensure effective sanitizing of the meal delivery cart had not been followed. DM stated, the specific sanitizing product had been in use in the kitchen for about a month. During an interview on 08/15/23, at 10:45 a.m., with [NAME] (Cook 2), [NAME] 2 was asked how he sanitized the food contact counter prior to use. [NAME] 2 stated, he used a spray bottle that contained Sink & Surface Cleaner Sanitizer, observed located on the lower shelf under trayline near the cook's station, and stated he keeps the sanitizer on the surface for 60 seconds. During a review of the poster for the sanitizing solution, the poster indicated Directions for Use .spraying or immersion until thoroughly wet for at least 60 seconds . Further review of the Sink & Surface Cleaner Sanitizer indicated, Kills SARS-CoV-2 [which causes COVID-19] in 15 seconds, Kills Norovirus, common cold and flu viruses in 30 seconds, and Kills bacteria and reduces the risk of foodborne illness in 60 seconds . (https://www.ecolab.com/offerings/sink-surface-cleaner-sanitizer). During a review of the commercial label for the Sink & Surface Cleaner Sanitizer, the label indicated to allow the solution to air dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 18 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, General Sanitation of Kitchen, dated 2017, the P&P indicated, Food and nutrition services staff will maintain the sanitation of the kitchen ., Method and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task, employees will be trained on how to perform cleaning tasks . During a review of the FDA (Food and Drug Administration) Food Code Annex 2022 (Annex), the Annex indicated, Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. (FDA Food Code Annex 2022; 4-901.11 Equipment and Utensils, Air-Drying Required) 2. During a concurrent interview and record review on 08/16/23 at 3:30 p.m., with a cook (Cook 2), the facility's Food & Nutrition: 2-Stage Cooling Temperature Log (CL), dated 9/3/22 through 6/27/23 was reviewed. The CL indicated, on 6/7/23, fortified soup began the cool down process at 7:20 a.m. at 172 degrees F (Fahrenheit) and at 9:20 a.m. the temperature of the soup was 75 degrees F, and had the initial of [NAME] 2. [NAME] 2 stated, when the fortified soup reached 75 degrees F after the 2 hour initial cool down process he then placed the fortified soup on ice and continued to cool down the soup for another four hours until it reached 38 degrees F at 1:20 p.m. [NAME] 2 was asked if the fortified soup was cooled down in accordance with the directions located on the CL. [NAME] 2 stated, No. During a concurrent interview and record review on 08/16/23 at 3:32 p.m., with Dietary Manager (DM), DM reviewed the logged entry, dated 9/19/22, on the CL and stated it was his initial's indicating he cooled down the fortified soup that day. DM reviewed the logged entry for 9/19/22 and stated the CL had not reflected correct and safe cool down procedures when the temperature of the fortified soup was 99 degrees F, after the 2-hour initial cool down. DM reviewed the CL and verified 3 of 5 logged entries on the CL was not done safely as the 2-hour initial cool temperatures were not down to 70 degrees F or less. DM verified the Corrective Action/Notification column located on the CL was blank. During a review of the directions located on the CL, the CL indicated, Instructions: Food must be cooled from 140 degrees F to 70 degrees F within the first 2 hours; 70 degrees F to 41 degrees F within the next 4 hours. If these temperatures are not reached in the appropriate time, corrective action is to throw away the food or to reheat to 165 degrees F for 15 seconds, then start cooling process again. This can only be done once. During a review of the facility's policy and procedure (P&P) titled, General HACCP [hazard analysis critical control point] Guidelines for Food Safety, dated 2017, the P&P indicated, Policy: Food and nutrition services staff will be educated and supervised on all HACCP information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP/Food Safety Program. Procedure: .Cooling: Safe cooling .to 70 degrees F in 2 hours and from 70 degrees F to 41 degrees F in 4 hours (not to exceed 6 hours). During a review of the FDA (Food and Drug Administration) Food Code 2022 (Food Code), the Food Code indicated, Cooling. Cooked time/temperature control for safety food shall be cooled: Within 2 hours from 135 degrees F to 70 degrees F . During a review of the FDA Food Code Annex 2022 (Annex), the Annex indicated, Time/Temperature Control for Safety Food .Bacterial growth and/or toxin production can occur if time/temperature control for safety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 19 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few food remains in the temperature Danger Zone . too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. During a review of the FDA Food Code Annex 2022 (Annex), the Annex indicated, The following guidance may be used for determining the appropriate corrective action for improper cooling. Cooked hot food may be reheated to 165 ºF for 15 seconds and the cooling process started again using a different cooling method if the food is: Above 70 ºF and two hours or less into the cooling process; and Above 41 ºF and six hours or less into the cooling process. Cooked hot food should be discarded immediately if the food is: Above 70 ºF and more than two hours into the cooling process; or Above 41 ºF and more than six hours into the cooling process. (FDA Food Code Annex 5; 7. Assessing Cooing) 3. During an observation on 08/15/23, at 09:16 a.m., in the dry food storage room in the kitchen, three different dry food storage stored flour, oatmeal, and thickener inside clear liners located in the bins. During an interview on 08/15/23, at 10:24 a.m., with Dietary Manager (DM), DM was asked if the clear liners used to store dry food ingredients were food grade liners and memory). DM stated, he was unsure and he pointed to the box of liners that were located on a high shelf in the dish machine room. The box of liners were labeled by the manufacturer as Sysco Classic Can Liners. There was no indication on the box that the liners were food grade. During an interview on 08/17/23, at 11:51 a.m., with DM, DM stated, he verified with Sysco the can liners used in the bins that stored the dry food ingredients were not food grade. DM verified food grade liners should be used when storing food. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated as revised 10/2017, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. During a review of the FDA Food Code 2022 Annex (Annex), the Annex indicated, Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment .Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants .may contaminate food if the packaging is inadequate . (FDA Food Code Annex; 3-302.1) During a review of the United States Department of Agriculture (USDA), USDA indicated, The use of plastic trash bags for food storage or cooking is not recommended because they are not food-grade plastic and chemicals from them may be absorbed into the food. (https://ask.usda.gov/s/article/Can-I-cook-or-store-foods-in-a-trash-bag) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 20 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly implement infection prevention and control practices according to recognized guidelines when: Residents Affected - Some 1. Personal protective equipment (PPE - gowns, gloves, masks, and face/eye protection to protect body from injury or infection) supplies required during contact with residents placed on Enhanced Standard/Barrier Precautions [ESBP - an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes and involve gown and glove use during high-contact resident care activities] were placed inside the room in close proximity to the residents. 2. A certified nursing assistant (CNA 3) was observed changing bed linen in a resident's room placed on ESBP without appropriate PPE. 3. An environmental services staff (ESS 1) failed to verbalize correct concentration of the diluted bleach solution used to cleanse and disinfect the floor in resident care areas. These failures had the potential to result in cross-contamination, spread of infectious agents, and ineffective disinfection of environmental surfaces. Findings: 1. During a review of the Centers for Disease Control (CDC's) guideline titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs), updated 7/12/22, the guideline indicated in part, When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. The guideline further indicated, To accomplish this: - Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves). - For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. - Make PPE, including gowns and gloves, available immediately OUTSIDE of the resident room. - Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). - Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. - Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices, such as hand hygiene and PPE use, to determine the need for additional training and education. - Provide education to residents and visitors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 21 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and record review, on 8/15/23, at 9:52 a.m., a tour of the resident care areas was conducted, and the following resident rooms (total of 11 rooms) were observed with ESBP signage posted outside the room: Rooms A-11, B-6, B-14, C-4, C-6, C-8, C-9, C-11, D-1, D-14, and D-15. The posted signage indicated, Enhanced Barrier Precautions . Everyone must: clean their hands including before entering and when leaving the rom. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care use [central line, urinary catheter, feeding tube, tracheostomy (a surgical opening that's made through the neck into the windpipe)], wound care (any skin opening requiring a dressing). The rooms were inspected for the location of the PPE supplies and mostly revealed the supplies were stored in hanging plastic organizers, hung just outside the resident's closet door. During a concurrent observation and interview, on 8/16/23, at 3:30 p.m., with the facility's Infection Preventionist (IP), a tour of the EBSP rooms was conducted. When asked why PPE supplies were stored inside the resident rooms, IP verbalized, the PPE supplies could be stored either inside or outside the rooms, but preferred them to be inside so staff could easily access them. IP acknowledged however, that unused PPE supplies inside the room had a higher probability of getting contaminated by both residents and staff. During a concurrent interview and record review, on 8/16/23, at 3:57 p.m., with IP, the CDC's guideline titled, Implementation of PPE Use in Nursing Homes to Prevent Spread of MDRO's, updated 7/12/22, was reviewed. The guideline indicated in part, Make PPE, including gowns and gloves, available immediately OUTSIDE of the resident room. IP verbalized understanding of the guideline and acknowledged PPE supplies would be less likely to become contaminated if stored outside the resident rooms. During a review of the facility's, policy and procedures (P&P), titled, Enhanced Standard Precautions, dated 6/16/23, the P&P indicated in part, Table 2. Guide for Using Enhanced Standard Precautions to Care for High-Risk SNF (Skilled Nursing Facility) Residents . Use of Gloves and Gowns . Rationale: Hand hygiene, gowns, and gloves prevent the transfer of infectious agents from the resident's skin, clothing, bedding, and environmental surfaces to the healthcare personnel's (HCP) skin and clothing. The P&P indicated further, Contamination of HCP skin and clothing is unlikely when contact with resident and any environmental surfaces in close proximity to the resident can be reliably avoided. 2. During a concurrent observation and record review, on 8/15/23, at 3:42 p.m., CNA 3 was observed changing bed linen inside Room D-14 with just gloves on as PPE. An ESBP signage was posted outside Room D-14, which partly indicated, Providers and Staff must also: wear gloves and a gown for the following high-contact resident care activities: .changing linens. During an interview, on 8/15/23, at 3:46 p.m., with CNA 3, CNA 3 was aware of the ESBP signage posted outside Room D-14, including the PPE requirements, but was not sure which resident was on ESBP. CNA 3 acknowledged, a gown should have been worn prior to changing bed linen regardless. During an interview, on 8/16/23, at 4:20 p.m., with IP, IP was informed that CNA 3 was observed changing bed linen in an ESBP room (Room D-14) with only gloves on as PPE. IP acknowledged, CNA 3 should have worn a gown as well, as indicated on the ESBP PPE requirements for high-contact resident care activities. 3. During a concurrent observation and interview, on 8/16/23, at 9:41 a.m., ESS 1 was observed cleaning a resident's room. ESS 1 showed the products used to cleanse and disinfect high-touch surfaces (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 22 of 23 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 555830 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lompoc Skilled Nursing & Rehabilitation Center 1428 West North Avenue 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in resident care areas as requested. When asked what solution was used daily to cleanse and disinfect the floors and during spills involving blood and body fluids, ESS 1 verbalized using a diluted bleach solution but could not describe the exact measurement or specific bleach concentration used, and stated, I mix a little bleach with water. During an interview, on 8/16/23, at 4:30 p.m., with IP, IP was informed that during an interview with ESS 1 on 8/16/23, at 9:41 a.m., ESS 1 did not know the exact measurement or bleach concentration of the solution used for the daily cleaning and disinfection of floors and during clean-up of blood/body fluid spills. IP acknowledged that all ESS should have understanding of the different concentration of bleach solution used in the facility and their effectiveness against specific infectious agents. During a review of the facility's, P&P, titled, Cleaning and Disinfecting Environmental Surfaces, undated, the P&P indicated in part, . 12) Disinfecting (or detergent) solutions will be prepared as needed and replaced with solution frequently (e.g., floor mopping solution will be replaced every three resident rooms, or as necessary) . 16) The following procedures will be implemented for site decontamination of spills of blood of other potentially infectious materials (OPIM): .c) If sodium hypochlorite (commonly known in dilute solution as bleach) are selected, use a 1:100 (1/4 cup of bleach in a gallon of water) dilution to decontaminate nonporous surfaces after a small spill (e.g., less than 10 ml) of either blood or OPIM, d) If a spill involves large amounts (e.g., more than 10 ml) of blood or OPIM . use a 1:10 dilution (1-1/2 cup cups of bleach in a gallon of water) . e) Follow this decontamination process with a terminal disinfection, using a 1:100 dilution of sodium hypochlorite. The P&P indicated further, . 19) In units with high rates of endemic Clostridium difficile infection (a bacterial infection of the colon causing diarrhea) or in an outbreak setting . 1:10 dilution of household bleach will be used for routine environmental disinfection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555830 If continuation sheet Page 23 of 23