COSTA MESA, CA - State inspectors found multiple safety and care deficiencies at Mesa Verde Post Acute Care Center during a June 2024 inspection, including improper handling of smoking materials, inadequate infection control practices, and medication documentation failures.
Smoking Safety Violations Create Fire Risk
Inspectors discovered that smoking materials were not being properly secured for residents, creating potential fire hazards throughout the facility. One resident was found storing cigarettes and a lighter in his room in a bag on the floor, despite facility policies requiring secure storage in designated locked containers.
When questioned, the resident stated "the facility did not let him store the cigarettes in his room but kept them because the facility would forget about them." However, nursing staff confirmed that residents were actually allowed to keep their own cigarettes and lighters, directly contradicting the facility's written smoking policy.
The facility's smoking policy, revised in July 2023, clearly stated that the interdisciplinary team should develop individualized plans for safe storage and supervision of smoking materials. Licensed practical nurse staff acknowledged the policy violation and immediately moved the smoking materials to a proper locked container at the nurse's station.
Improper storage of smoking materials in healthcare facilities presents serious fire safety risks. Cigarettes and lighters should always be stored in designated, secure locations away from oxygen sources and other flammable materials. The combination of portable oxygen equipment, medical devices, and combustible materials creates an environment where a small fire can rapidly spread and cause catastrophic damage.
Catheter Care Failures Lead to Infection Risk
A significant infection control violation was identified involving a resident with a suprapubic catheter who had a history of recurring urinary tract infections. Inspectors observed the resident's urinary drainage bag lying on the floor multiple times, which directly violates established medical protocols and increases infection risk.
The resident, who was actively being treated for a UTI at the time of inspection, stated "he would put the urinary drainage bag on the floor himself and sometimes put it in a trash bag" and that "the facility did not educated him about the urinary drainage bag being placed on the floor."
According to Centers for Disease Control and Prevention guidelines, urinary drainage bags must be kept below the level of the bladder at all times and should never rest on the floor. This positioning prevents urine from flowing backward into the bladder, which can introduce bacteria and cause catheter-associated urinary tract infections (CAUTIs).
CAUTIs are among the most common healthcare-associated infections and have been linked to increased illness, mortality, hospital costs, and length of stay. Proper catheter maintenance requires keeping drainage bags in dignity bags, positioning them correctly, and educating both residents and staff about infection prevention protocols.
The facility's failure to educate the resident about proper catheter care represents a breakdown in both clinical oversight and patient education. Healthcare facilities must ensure that residents with indwelling catheters understand the importance of proper drainage bag positioning and receive consistent reinforcement of these safety measures.
Respiratory Equipment Storage Violations
Multiple respiratory care violations were documented across four residents, involving improper storage and labeling of critical breathing equipment. Inspectors found nasal cannulas, nebulizer masks, and CPAP equipment stored improperly, creating contamination risks for vulnerable residents with respiratory conditions.
Oxygen tubing was found unlabeled and undated, nebulizer masks were stored in drawers without protective bags, and CPAP masks were left exposed on bedside tables. Facility policy requires all respiratory equipment to be labeled with dates, stored in protective bags when not in use, and replaced every seven days to prevent bacterial growth and cross-contamination.
These violations are particularly concerning given that the affected residents had serious respiratory conditions including acute pulmonary edema, asthma, and sleep apnea requiring continuous positive airway pressure therapy. Contaminated respiratory equipment can introduce harmful bacteria directly into the lungs, potentially causing pneumonia or other serious respiratory infections.
Proper respiratory equipment management requires immediate labeling when equipment is first used, secure storage in protective containers between uses, and regular replacement according to manufacturer guidelines. The facility's systematic failure across multiple residents suggests inadequate staff training and supervision in respiratory care protocols.
Medication Management Failures
Critical medication documentation failures were identified involving controlled pain medications, creating potential for drug diversion. Inspectors found discrepancies between controlled substance logs and electronic medication administration records for two residents receiving oxycodone and Norco.
The Individual Narcotic Records showed controlled medications were removed from locked storage, but corresponding entries were missing from the electronic medication administration records. This documentation gap makes it impossible to verify whether residents actually received their prescribed pain medications or whether controlled substances were diverted for unauthorized use.
Federal regulations require immediate documentation in both controlled substance logs and medication administration records when controlled medications are given. This dual documentation system creates accountability and helps prevent medication errors or theft.
The facility's controlled medication policy requires nurses to document the date, time, amount administered, and nurse initials in both the accountability record and the medication administration record immediately after giving controlled substances. The documented failures represent serious breaches of controlled substance protocols that could result in regulatory action and potential criminal investigation.
Additional Issues Identified
Inspectors documented several other violations including inadequate dialysis care monitoring, improper tube feeding documentation, pharmacy recommendation follow-up failures, expired medication storage, and food service sanitation problems. These additional findings point to systemic quality assurance issues affecting multiple aspects of resident care and safety.
The dialysis care violation involved failure to properly assess a resident's arteriovenous shunt site after returning from dialysis treatment, despite physician orders requiring monitoring every shift. Tube feeding violations included missing start times and nurse initials on feeding labels, making it impossible to track hang times and prevent bacterial contamination.
Kitchen sanitation violations included unlabeled frozen foods, improperly stored resident food items, dirty ice machines with yellowish residue, food debris on cooking equipment, and cutting boards in unsanitary conditions. These conditions create foodborne illness risks for medically vulnerable residents.
The inspection findings reveal widespread deficiencies across multiple departments at Mesa Verde Post Acute Care Center, suggesting the need for comprehensive quality improvement initiatives and enhanced staff training programs to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Verde Post Acute Care Center from 2024-06-06 including all violations, facility responses, and corrective action plans.
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