Mesa Verde Post Acute Care Center

F-F656, example #2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476

Residents Affected - Few Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide

a safe environment free from potentially serious accident hazards for one of one residents who were reviewed for smoking (Resident 24). The facility failed to ensure the smoking materials for Resident 24 were securely stored. This posed the risk of fire and serious injuries to the residents who resided in the facility.

Findings:

Review of the facility's P&P titled Smoking Residents revised 7/27/23, showed the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance, and/or required supervision, for residents who smoke.

On 6/5/24 at 0415 hours, an observation and concurrent interview was conducted with Resident 24 in his room. A box of cigarettes was observed to be stored inside a bag on the ground. When asked about the cigarettes, Resident 24 stated the facility did not let him store the cigarettes in his room but kept them because the facility would forget about them.

Medical record review for Resident 24 was initiated on 6/3/24. Resident 24 was readmitted to the facility on [DATE REDACTED].

Review of Resident 24's H&P examination dated 7/1/23, showed Resident 24 had the capacity to understand and make decisions.

Review of Resident 24's plan of care showed a care plan problem dated 11/24/2, to address Resident 24's tobacco use. The interventions included for the cigarettes and lighter to be stored in a designated box.

On 6/5/24 at 0425 hours, an observation and concurrent interview was conducted with LVN 4 for Resident 24

in Resident 24's room. LVN 4 acknowledged the above findings. LVN 4 stated the facility allowed Resident 24 to have his own cigarettes and lighter. LVN 4 stated Resident 24 kept his cigarettes in his room and verified the facility did not take his smoking materials for safe storage.

On 6/5/24 at 0448 hours, an observation and concurrent interview was conducted with RN 2. RN 2 verified

the above findings. RN 2 stated the cigarettes should not be kept in his room and should be kept in a locked box with his name and room number. RN 2 proceeded to take Resident 24's cigarettes, then placed them into a locked container located in the nurse's station.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476

Residents Affected - Few Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTI (urinary tract infection, a condition associated with invasion by disease causing microorganisms of some part of the urinary tract) for one of one resident (Resident 24) reviewed for urinary catheter or UTI. Resident 24 had a suprapubic catheter (a tube used to drain urine from the bladder through

an incision in the abdomen) and a history of recurrent UTIs. The facility failed to ensure proper positioning of Resident 24's urinary drainage bag to prevent urine from flowing back into the bladder. This posed the risk for Resident 24 to develop a catheter-associated urinary tract infection (CAUTI).

Findings:

Review of the Centers for Disease Control and Prevention's (CDC) topic titled Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline dated 4/2024, showed urinary tract infections are the most common type of healthcare associated infection. CAUTI has been associated with increased morbidity, mortality, hospital cost, and length of stay. The section titled Proper Techniques for Urinary Catheter Maintenance, showed to keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

During an initial tour of the facility on 6/3/24 at 1246 hours, Resident 24 was observed laying in bed with an urinary catheter tubing attached to a urinary drainage bag. The urinary drainage bag was observed laying on

the floor.

Medical record review for Resident 24 was initiated on 6/3/24. Resident 24 was readmitted to the facility on [DATE REDACTED].

Review of Resident 24's H&P examination dated 7/1/23, showed Resident 24 had the capacity to understand and make decisions.

Review of Resident 24's Change in Condition Evaluation dated 5/29/24, showed Resident 24 had a UTI started on 5/29/24 and was started on antibiotics.

On 6/5/24 at 0415 hours, an observation and concurrent interview was conducted with Resident 24. Resident 24's urinary drainage bag was observed laying on the floor. Resident 24 stated he currently had a UTI. Resident 24 stated he would put the urinary drainage bag on the floor himself and sometimes put it in a trash bag. Resident 24 stated the facility did not educated him about the urinary drainage bag being placed on the floor.

On 6/5/24 at 0425 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified

the above findings. LVN 4 stated the urinary drainage bag should not be on the floor because of bladder problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0690 On 6/5/24 at 0545 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator was informed and acknowledged the above findings. The MDS Coordinator stated Resident 24 had a suprapubic Level of Harm - Minimal harm or catheter and history of recurrent UTIs. The MDS Coordinator stated the urinary drainage bag should be kept potential for actual harm in a dignity bag and not placed on the floor for infection control.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50126

Residents Affected - Some Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide

the necessary GT care and services for one of one resident reviewed for GT care (Resident 45).

*Resident 45's GT feeding bottle label did not indicate the start time of the feeding and the initials of the nurse who hung the tube feeding.

This failure had the potential for the residents to develop complications related to tube feedings and/or risk for infections.

Findings:

Review of the facility's P&P titled Enteral Feedings 9/7/23, showed to label the bag and tubing with the date and time hung. Hang time is for no more than 24 hours.

On 6/3/24 at 1235 hours and 6/4/24 at 1145 hours, an observation was conducted with Resident 45. Resident 45's tube feeding bottle label was observed with the resident's name, room number, and date. However, the tube feeding label did not include the start time and the nurse's initials who hung the tube feeding.

Medical record review for Resident 45 was initiated on 6/5/24. Resident 45 was admitted to the facility on [DATE REDACTED].

Review of Resident 45's H&P examination dated 4/15/24, showed Resident 45 had no capacity to understand and make decisions.

Review of Resident 45's Order Summary Report dated 6/6/24, showed a physician's order dated 5/22/24, to administer Jevity 1.2 (a type of feeding formula) at 65 ml/hr via pump for 20 hours to provide 1200/ml or 1560 kcals.

On 6/3/24 at 1430 hours, an interview was conducted with the IP. When asked about the process for labeling

the tube feeding when the bottle was changed, the IP stated the tube feeding was changed during the night shift. The label needed to have the resident's name, date hung, start time, room number, and the nurse's initials. The IP verified the tube feeding label did not include the start time and the nurse's initials.

On 6/5/24 at 0739 hours, an interview was conducted with LVN 1. When asked about the process for labeling the tube feeding when the bottle was changed, LVN 1 stated the tube feeding was changed during

the night shift. LVN 1 stated the label needed to have the resident's name, date hung, start time, room number, and the nurse's initials.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0693 On 6/5/24 at 0951 hours, an interview was conducted with the DON and Administrator. The DON stated the tube feeding label should include the resident's name, date, time started, room number, and initials of the Level of Harm - Potential for nurse. The DON further stated the facility's enteral feeding policy should have included the initials of the minimal harm nurse who hung the tube feeding. The Administrator was informed and acknowledged the above findings.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39670 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few four of four residents reviewed for respiratory care (Residents 14, 50, 44, and 623) were provided with the appropriate respiratory care when:

* The facility failed to ensure the nasal cannula was dated and labeled, and the nebulizer mask was stored properly for Residents 14 and 50.

* The facility failed to ensure the CPAP mask was stored properly for Resident 623.

* The facility failed to ensure the nasal cannula was stored properly for Resident 44.

These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Findings:

Review of the facility's P&P titled Oxygen Therapy dated 11/2017 showed oxygen is administered under safe and sanitary conditions to meet resident needs. Administer oxygen per physician's order and tubing, mask, and cannulas should be changed every seven days and labeled with the date of change.

1. During the initial facility tour on 6/3/24 at 1051 hours, Resident 14 was observed in bed and with a nebulizer machine on top of the bedside drawer. A nebulizer mask was stored inside the top drawer and not

in a respiratory bag.

Medical record review for Resident 14 was initiated on 6/4/24. Resident 14 was admitted to the facility on [DATE REDACTED].

Review of Resident 14's H&P examination dated 5/2/24, showed Resident 14 had the capacity to understand and make decisions.

Review of Resident 14's Order Summary Report dated 6/4/24, showed a physician's order dated 5/7/24, to administer albuterol sulfate nebulization solution (2.5 mg per 3 ml) 0.083% 3 ml inhale orally two times a day and every six hours as needed for shortness of breath or asthma (lung disease causing the airways to narrow, swell and produce extra mucus).

2. During the facility initial tour on 6/3/24 at 1054 hours, Resident 50 was observed lying in bed wearing a nasal cannula attached to an oxygen machine with a setting of three liters per minute, the oxygen tubing was unlabeled. A nebulizer mask was stored on top of the bedside drawer unlabeled and not in a respiratory bag.

Medical record review for Resident 50 was initiated on 6/4/24. Resident 50 was admitted to the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0695 Review of Resident 50's H&P examination dated 5/16/24, showed Resident 50 had no capacity to understand and make decisions, and had a diagnosis of acute pulmonary edema (excessive fluid Level of Harm - Minimal harm or accumulation in the lungs) and shortness of breath. potential for actual harm

Review of Resident 50's Order Summary Report dated 6/4/24, showed the following physician's orders: Residents Affected - Few -dated 5/15/24, to administer oxygen via nasal cannula at four liters per minute to keep oxygen saturation above 93 % for shortness of breath.

-dated 5/15/24, to administer ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg per ml inhale orally three times a day and every four hours as needed for shortness of breath.

On 6/3/24 at 1026 hours, an observation and concurrent interview for Resident 14 and 50 was conducted with LVN 7. LVN 7 verified the above findings. LVN 7 stated the nebulizer mask should have been placed in

a clear plastic bag.

On 6/3/24 at 1035 hours, an interview for Resident 14 and 50 was conducted with RN 1. RN 1 stated the nebulizer mask and oxygen tubing should have been placed in a clear plastic bag after each use and with a label. RN 1 verified the above findings.

On 6/6/24 at 1020 hours, an interview for Resident 14 and 50 was conducted with the DON. The DON was informed and verified the above findings.

47476

3. Review of the facility's P&P titled BiPAP and CPAP revised 10/2019 showed equipment should be kept in

a labeled plastic bag with resident name or container provided by the machine manufacturer.

During an initial tour of the facility on 6/3/24 at 0941 hours, Resident 623's CPAP mask was observed laying

on top of Resident 623's bedside drawer. Resident 623 was not observed to be in his room.

On 6/3/24 at 1143 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified

the above findings and stated the CPAP mask should be stored in a plastic bag when not in use.

Medical record review for Resident 623 was initiated on 6/3/24. Resident 623 was admitted to the facility on [DATE REDACTED].

On 6/5/24 at 0541 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator was informed and acknowledged the above findings. The MDS Coordinator stated the CPAP mask should be stored in a respiratory bag.

4. During an initial tour of the facility on 6/3/24 at 0944 hours, Resident 44's nasal cannula tubing was observed laying on top of Resident 44's wheelchair, not being used.

On 6/3/24 at 1143 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified

the above findings and stated the nasal cannula should be stored in a plastic container when not in use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0695 Medical record review for Resident 44 was initiated on 6/3/24. Resident 44 was readmitted to the facility on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm On 6/5/24 at 0541 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator was informed and acknowledged the above findings. The MDS Coordinator stated the nasal cannula tubing Residents Affected - Few should be stored in a respiratory bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39670 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents Affected - Few the dialysis care was provided for one of one final sampled resident reviewed for dialysis services (Resident 29) as evidenced by:

* The facility failed to ensure Resident 29's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to assess Resident 29's dialysis access site after returning from

the dialysis clinic accurately. In addition, the licensed staff failed to document an assessment of Resident 29's dialysis access upon return from the dialysis clinic.

These failures had the potential for Resident 29 not being provided with appropriate care and treatment and

the possibility of medical complications related to the resident's dialysis access site.

Findings:

Review of the facility's P&P titled Dialysis Care revised 10/1/18, showed for the licensed staff caring for the residents with dialysis AV (Arteriovenous) shunt should inspect for functionality and sign and symptoms of complications. Documentation included pre/post dialysis assessment, dialysis flow sheet-return assessment, and dialysis medical intake sheet.

On 6/3/24 at 1058 hours, an interview was conducted with Resident 29. Resident 29 stated she received dialysis on Tuesdays, Thursdays, and Saturdays.

Medical record review for Resident 29 was initiated on 6/4/24. Resident 29 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED].

Review of Resident 29's H&P examination dated 5/29/24, showed Resident 29 had the capacity to understand and make decisions.

Review of Resident 29's Order Summary Report the following physician's orders dated 5/29/24:

- dialysis every Tuesday and Saturday for 4 hours at dialysis center.

- to monitor the AV shunt on left upper arm for bruit and thrill every shift.

- to observe the AV shunt site and dressing on left upper arm and change as directed by the physician every shift.

Review of Resident 29's Pre-Dialysis Evaluation dated 6/1/24, showed Resident 29 refused to complete the four hours treatment and signed against medical advice. However, further review of the medical records failed to show documented evidence on the information as to what was the reason of Resident 29's refusal to finish the therapy, for how many hours did Resident 29's treatment was completed, and if the physician was notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0698 On 6/6/24 at 0902 hours, an observation and concurrent interview for Resident 29 was conducted with LVN 3. Resident 29 was observed in bed with a dry dressing on the left upper arm dialysis access. Resident 29 Level of Harm - Minimal harm or stated she received dialysis yesterday and came back to the facility around 1530 hours. LVN 3 verified a dry potential for actual harm dressing on the left upper arm of Resident 29. LVN 3 stated the licensed staff who received the resident from dialysis should have assessed the resident, including the access site. LVN 3 stated the dressing should be Residents Affected - Few remove four hours after dialysis, to have an accurate assessment of the dialysis access site.

Further review of Resident 29's medical record failed to show a post dialysis assessment on 6/5/24.

On 6/6/24 at 0923 hours, an interview and concurrent medical record review for Resident 29 was conducted with RN 1. RN 1 was asked for the post dialysis assessment of Resident 29 on 6/5/24. RN 1 was unable to find documented evidence an assessment was done when Resident 29 was received from the dialysis center. RN 1 was asked about the assessment of the dialysis access site of the resident. RN 1 stated the dialysis access site dressing should have been removed for an accurate assessment.

On 6/6/24 at 1049 hours, an interview and concurrent medical record review for Resident 29 was conducted with the DON. The DON was informed and verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683

Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of two residents (Residents 17 and 23) reviewed for controlled medication administration.

*The facility failed to ensure Resident 17 and 23's controlled pain medications were accurately reconciled.

The controlled pain medications removed as shown on the Individual Narcotic Record were not recorded as administered on the electronic MAR. This failure had the potential for drug diversion.

Findings:

Review of the facility's P&P Preparation and General Guidelines - IIA5: Controlled Medications dated August 2014 showed when a controlled medication is administered, the nurse will immediately document the following in the accountability record and the MAR:

-the date and time of administration, the amount administered, and the initials of the nurse administering the medication in the MAR.

1. Medical record review for Resident 17 was initiated on 6/4/24. Resident 17 was admitted to the facility on [DATE REDACTED].

Review of Resident 17's Individual Narcotic Record for oxycodone hcl (controlled pain medication) 10 mg tablets, initiated 5/18/24, showed one tablet was removed from the supply on 5/23/24 at 1400 hours.

Review of Resident 17's MAR for May 2024, failed to show oxycodone hcl 10 mg was documented as administered on 5/23/24.

On 6/4/24 at 0824 hours, an interview and concurrent medical record review were conducted with LVN 1. LVN 1 verified Resident 17's medical record and verified the oxycodone hcl 10 mg tablet was removed from

the supply on 5/23/24 at 1400 hours, but it was not documented on the resident's MAR.

2. Medical record review for Resident 23 was initiated on 6/4/24. Resident 23 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 23's Individual Narcotic Record for Norco (controlled pain medication) 5-325 mg tablets, initiated 5/16/24, showed one tablet was removed from the supply on 6/3/24 at 2140 hours.

Review of Resident 23's MAR for June 2024, failed to show Norco 5-325 mg was documented as administered on 6/3/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0755 On 6/4/24 at 0824 hours, an interview and concurrent medical record review were conducted with LVN 1. LVN 1 Resident 23's medical record and verified the Norco 5-325 mg tablet was removed from the supply on Level of Harm - Minimal harm or 6/3/24 at 2140 hours, but it was not documented on the resident's MAR. LVN 1 stated the above controlled potential for actual harm medications should have been documented on the MAR.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32179

Residents Affected - Few Based on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five residents reviewed for unnecessary medications(Residents 61). This failure had the potential to put Resident 61 at risk for adverse consequences related to the medication.

Findings:

1. Medical review of Resident 61 was initiated on 6/3/24. Resident 61 was admitted to the facility on [DATE REDACTED].

Review of Resident 61's Order Summary Report dated 5/28/24, showed a physician's order dated 1/12/24, to administer buspirone HCL (antianxiety medication) 5 mg one tablet by mouth two times a day for anxiety manifested by restlessness.

Review of Resident 61's Consultant Pharmacist's Medication Regimen Review between 5/1/24 and 5/13/24, showed agitation or restlessness too subjective and should not be used as a diagnosis nor as a behavior. Please updated the order with a specific and quantifiable behavior.

Further review of Resident 61's medical record did not show documented evidence Resident 61's physician was notified or if the Pharmacy Consultant's recommendation for the buspirone was acted upon.

On 6/5/24 at 1115 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked regarding the pharmacy recommendation for Resident 61's buspirone medication. RN 1 stated

she had followed up with the physician and the manifested behavior was changed to resisting care. RN 1 was asked to provide the documentation to show who the doctor she spoke with and when was she made

the call. RN 1 was unable to provide the documentation. RN verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683 Residents Affected - Few Based on observation, interview, and facility P&P review, the facility failed to ensure the expired and potentially deteriorated medications were removed from the supply for two of three medication carts (Medication Carts A and B). This had the potential for expired or deteriorated medications to be administered to the residents.

Findings:

Review of the facility's P&P Medication Storage In The Facility effective [DATE REDACTED] showed outdated or deteriorated medications will be immediately removed from stock and disposed of.

1. On [DATE REDACTED] at 1219 hours, an inspection of Medication Cart B was conducted with RN 1. Two 10 ml vials of injectable sterile water with the expiration dates of [DATE REDACTED] and [DATE REDACTED], were observed in the cart. RN 1 verified the two vials were expired and stated the expired vials should have been removed from the cart.

2. On [DATE REDACTED] at 1406 hours, an inspection of Medication Cart A was conducted with LVN 1. A box of budesonide (medication used to reduce irritation and swelling of the airways) inhalation solution 0.5 mg/2 ml was observed. Inside the box was an open foil package dated [DATE REDACTED], with two ampules remaining. The medication box showed once the foil envelope was opened, use the ampules within two weeks. LVN 1 reviewed the medication box instructions and verified the remaining medication in the opened foil envelope should have been removed from the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 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. Level of Harm - Minimal harm or potential for actual harm 39453

Residents Affected - Few Based on observation, interview, and facility document review, the facility failed to follow the menu.

*Cook 1 did not follow the recipe when preparing pureed Spinach Au Gratin (creamed spinach topped with cheese and baked in the oven)

*Scoop #12 was used to serve regular Spinach Au Gratin instead of scoop #8 per the spreadsheet.

These failures had the potential of the menu not meeting the residents' nutritional needs which could lead to nutritional related health complications.

Findings:

Review of the Order Listing Report dated 6/3/24, showed eight residents were on pureed diet, and 68 residents on regular diet, with no restrictions to vegetable or spinach or cheese.

1. Review of the facility's document titled Summer Menus for Week 1 Tuesday dated 6/4, 7/2, 7/30, and 8/27/24, for lunch showed to serve Spinach Au Gratin for lunch.

Review of the facility's document titled Recipe: Spinach Au Gratin, Week 1 Tuesday showed to cook spinach

in enough water to cover, drain well and place in baking pan. Add margarine and cheese and mix well.

On 6/4/24 at 1029 hours, an observation of the pureed food preparation and concurrent interview was conducted with [NAME] 1. During the pureed vegetable preparation, [NAME] 1 was observed taking a silver container with spinach. [NAME] 1 stated the spinach was boiled with soup base. [NAME] 1 continued to puree the spinach and added thickener to the pureed recipe. [NAME] 1 was observed placing the pureed spinach into the oven. When asked if anything was added or to be added to the spinach, [NAME] 1 answered no.

On 6/4/23 at 1100 hours, an interview and concurrent facility document review was conducted with [NAME] 1 and the DSS. [NAME] 1 and the DSS verified the above findings.

2. Review of the facility's document titled Summer Menus for Week 1 Tuesday dated 6/4, 7/2, 7/30, and 8/27/24, for lunch, showed to serve 1/2 cup of Spinach Au Gratin for regular diet (small, regular, large portions), and also for mechanical soft diet.

Review of the facility's document titled Portion Control Chart (undated) showed to control accurate food costs and find the correct disher/ scoop utensil for the serving size. The chart showed for 1/2 cup serving size to use disher/ scoop size #8 (gray).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 On 6/4/24 at 1150 hours, a trayline observation with [NAME] 1, and concurrent interview and concurrent traycart inspection was conducted with the DSS. [NAME] 1 was observed using disher/ scoop size #12 to Level of Harm - Minimal harm or serve Spinach Au Gratin for regular diet. A traycart was observed near the kitchen door. The DSS stated the potential for actual harm trays in the cart were ready to be delivered to the residents. During the traycart inspection, several trays were observed with Spinach Au Gratin for residents on regular diet and mechanical soft diet. When asked Residents Affected - Few about the scoop used for regular Spinach AuGratin, the DSS verified the serving size was not what was stated on the spreadsheet for the regular Spinach AuGratin. The DSS acknowledged [NAME] 1 should have used #8 scoop instead of #12 scoop to serve the regular Spinach Au Gratin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 39453

Residents Affected - Few Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by:

* The facility failed to ensure proper labeling and dating of foods in the kitchen.

*The facility failed to ensure the food items inside the refrigerator used for residents' food brought in from outside were properly stored per the facility's P&P.

* The ice machine was dirty with yellowish slimy residue in the upper inside part of the ice maker area.

* The kitchen exhaust hood was observed with brownish black residue.

* The facility failed to ensure the proper sanitary condition of the kitchen equipment. The oven and heated plate dispenser were observed with food debris.

* The facility failed to ensure the kitchen items were air dried.

* The facility failed to ensure cutting boards were kept in a sanitary condition.

These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Findings:

Review of the facility's document titled Order Listing Report dated 6/3/24, showed 71 of 72 residents in the facility received food prepared in the kitchen.

1. According to FDA Food Code 2022, Section 3-501.17, Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking, showed date marking requirements apply to containers of processed food that have been opened and to food prepared, if held for more than 24 hours, by marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed.

Review of the facility's P&P titled Food Storage revised date 7/25/19, showed food items will be stored, thawed, and prepared in accordance with good sanitary practice. All times will be correctly labeled and dated.

On 6/3/24 at 0805 hours, during the initial tour of the kitchen, a bag of frozen egg omelets, a bag of frozen smores doodle cookies, a bag of frozen donuts and a bag of frozen blueberries were observed with no opened date inside Freezer #2. The DSS verified the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 2. Review of the facility's P&P titled Food Brought In by Visitors revised 6/2018 showed when food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container Level of Harm - Minimal harm or is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this potential for actual harm purpose.

Residents Affected - Few a. On 6/5/24 at 0734 hours, an inspection of the refrigerator used for residents' food brought in from outside was conducted with LVN 3. The following was observed inside the freezer:

-A box of chimichangas was observed labeled with resident name, and DD 6/2/24; and

-Four unlabeled bags of ice.

LVN 3 verified the above findings. LVN 3 stated DD meant due date, and the bags of ice were for a resident who brought his own ice.

b. On 6/5/24 at 1131 hours, several fruits and unlabeled food containers were observed on the Resident 58's bedside table, overbed table, floor, and on the bed.

On 6/5/24 at 1203 hours, an observation and concurrent interview was conducted with CNA 2. Several fruits and unlabeled food containers were observed on Resident 58's bedside table, overbed table, floor, and on

the bed. CNA 2 verified the above findings. CNA 2 stated the facility was aware of the food containers, and fruits brought in by the resident's family members.

On 6/5/24 at 1211 hours, an interview and concurrent observation was conducted with LVN 3. LVN 3 verified

the above findings.

Cross-reference to

F-F684.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47476 potential for actual harm Based on observation, interview, medical record review, and facility document review, the facility failed to Residents Affected - Few provide the necessary treatment and services for one of three residents who were reviewed for positioning and mobility (Resident 17). The facility failed to apply a cervical collar (c-collar) to Resident 17 as ordered by

the physician. This failure had the potential to negatively affect the Resident 17's health and well-being.

Findings:

Review of the facility document titled Your Path to Recovery After Cervical Spine Surgery revised 11/2015 showed a cervical collar is worn at the discretion of the surgeon. Under the section titled Spine Precautions, showed a cervical collar is used to provide support and limit movement of the neck. Your doctor may or may not order a cervical collar. Typically, the collar should be worn at all times. Cervical collar is worn at the discretion of the surgeon.

During an initial tour of the facility on 6/3/24 at 0845 hours, Resident 17 was observed lying in bed. A c-collar was observed on the top of Resident 17's bedside drawer. Resident 17 stated he was hit by car a couple weeks ago while he was in his wheelchair.

Medical record review for Resident 17 was initiated on 6/3/24. Resident 17 was admitted to the facility on [DATE REDACTED].

Review of Resident 17's Psych Progress Note dated 4/24/24, showed Resident 17 had the capacity to understand and make his own medical decisions.

Review of Resident 17's Order Summary Report dated 6/5/24, showed a physician's order dated 4/12/24, for

the application of the c-collar on at all times, TLSO for out of bed activities or HOB greater than 30 degrees.

Review of Resident 17's plan of care failed to show the application of the c-collar, TLSO when out of bed, or noncompliance were addressed.

On 6/4/24 at 1138 hours, Resident 17 was observed lying in bed without a c-collar on.

On 6/4/24 at 1534 hours, an interview and concurrent medical record review was conducted with the DOR.

The DOR verified Resident 17 did not wore the c-collar as ordered by the physician. The DOR stated Resident 17 received a c-collar and a back brace but was non-compliant with wearing both. The DOR stated Resident 17 should have had a follow up appointment with the orthopedic specialist and the c-collar order could only be addressed by an orthopedic specialist.

On 6/4/24 at 1550 hours, an interview was conducted with RNA 1. RNA 1 verified Resident 17 was currently receiving RNA services. RNA 1 stated Resident 17 did not use a brace and stated she was never instructed to apply a c-collar or back brace on Resident 17.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0684 On 6/4/24 at 1600 hours, an interview and concurrent record review was conducted with LVN 5. LVN 5 verified she had never seen Resident 17 wearing a c-collar or back brace and/or attempted to apply one for Level of Harm - Minimal harm or Resident 17 per the physician's orders. LVN 5 stated she was not aware of why Resident 17 was not using potential for actual harm the c-collar.

Residents Affected - Few On 6/5/24 at 0528 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 stated Resident 4 did not use the c-collar or back brace and did not know if Resident 17 needed them. LVN 4 stated

she was not sure if Resident 17 had refused to wear the c-collar. LVN 4 then went inside Resident 17's room and asked Resident 17 about the c-collar. Resident 17 was observed to be without a c-collar on and stated it was very uncomfortable to wear.

On 6/5/24 at 0530 hours, an interview and concurrent medical record review was conducted with the DON and MDS coordinator. The DON and MDS Coordinator were informed and acknowledged the above findings.

The DON stated Resident 17 had been refusing to wear the c-collar and the physician was aware, however,

the DON was unable to provide documented evidence the physician or orthopedic specialist was notified about Resident 17's refusal. The MDS Coordinator verified Resident 17 had not been seen by an orthopedic specialist during his admission to the facility.

Cross reference to

F-F812 example #2b.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 39453 potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to dispose of trash properly. One Residents Affected - Few of three dumpsters was observed overflowing with boxes, which prevented the lid from fully closing. This had

the potential to attract and harbor pests and/ or rodents.

Findings:

According to FDA Food Code 2013, 5-501.113, Covering Receptacles, receptacle and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids.

On 6/4/24 at 0755 hours, three dumpsters and one food waste bin were observed outside adjacent to the facility. One dumpster was observed with the lid propped open by boxes, which prevented the lid from fully closing.

On 6/4/24 at 0803 hours, an observation of trash disposal and concurrent interview was conducted with the Director of Maintenance. One of three dumpsters outside adjacent to the building was observed overflowing with boxes and the lid was not fully closed. The Director of Maintenance verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39683

Residents Affected - Few Based on observation, interview, medical record review and facility document review, the facility failed to maintain accurate and confidential resident records.

* The facility failed to ensure confidential resident rosters were not included in the CDPH Survey results binder for public review.

* The facility failed to ensure Resident 29's monthly weight was documented correctly.

These failures had the potential for protected information to be viewed by the public and the resident's care needs not being met as the medical information was incomplete and inaccurate.

Findings:

1. On 6/5/24 at 0926 hours, a binder labeled CDPH Annual Survey Binder was observed on a table in the lobby for public review. Review of the binder showed the following confidential resident rosters:

- a confidential resident roster dated 8/31/21, with two residents' names and their identifiers

- a confidential resident roster dated 9/1/21, with two residents' names and their identifiers

- a confidential resident roster dated 9/15/21, with two residents' names and their identifiers

On 6/5/24 at 0937 hours, an interview and concurrent facility document review were conducted with the Administrator. The Administrator verified three confidential resident rosters were in the CDPH Annual Survey Binder and should not have been there.

39670

2. Medical record review for Resident 29 was initiated on 6/4/24. Resident 29 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

Review of Resident 29's monthly weights for the past six months, showed the following monthly weights:

- On 1/5/24 = 165.0 lbs

- On 2/1/24 = 169.1 lbs

- On 4/8/24 = 159.9 lbs

- On 5/3/24 = 161.7 lbs

- On 6/1/24 = 70.6 lbs

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0842 Further review of the medical record failed to show documented evidence Resident 29 had significant weight loss. Level of Harm - Minimal harm or potential for actual harm On 6/6/24 at 1055 hours, an interview and concurrent medical record review for Resident 29 was conducted with the DON. The DON stated she entered the monthly weight results in the electronic medical records. The Residents Affected - Few DON verified the monthly weight data results were entered in error. The DON verified the monthly weight results for June was entered in kilograms and it should have been converted into pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 32179 potential for actual harm Based on observation and interview, the facility failed to ensure the appropriate infection control practices Residents Affected - Few were implemented to provide a safe and sanitary environment and prevent the spread of infections within the facility.

* There were multiple briefs and blue chucks stacked on the top of an isolation chart located in front of room A.

This failure posed the risk of transmission of infectious organisms from the floor to the residents in the facility.

Findings:

On 6/5/24 at 0410 hours, multiple briefs and blue chucks were observed stacked on the top of the isolation cart.

On 6/5/24 at 0515 hours, CNA 3 took the briefs and chucks to be distributed to rooms A, B, and Resident 18's room.

On 6/5/24 at 0520 hours, an interview was conducted with CNA 3. CNA 3 stated she put the briefs and chucks there to distribute them to different residents. CNA 3 acknowledged the briefs and chucks should not be placed on the top of isolation cart due potential contamination and spread of infection. CNA 3 verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 39453 potential for actual harm Based on observation, interview, facility document review, equipment instruction manual review, and facility Residents Affected - Few P&P review, the facility failed to maintain the essential equipments in safe operating condition.

* The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification, and per the facility's P&P. An incorrect ratio of the nickel-safe cleaner was used to descale the ice machine, a hot water instead of a sanitizing solution was used to sanitize the inside of the machine, and

an unidentified and unlabeled spray bottle was used to sanitize the panels of the ice machine. These failures had the potential for the equipment to not function in the way it was intended, which could cause food-borne illnesses for the residents.

* The glucometer in Medication Cart A's serial number did not match the glucometer serial number listed on

the Quality Control Record. This failure post a risk for incorrect blood sugar reading resulting to incorrect blood sugar management that can negatively affect the resident's well-being.

Findings:

1. Review of the facility's document titled Order Listing Report dated 6/3/24, showed 71 of 72 residents in the facility received food prepared in the kitchen.

According to FDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk.

Review of the Ice-O-Matic Installation Guide and Owner's Manual dated 02/2020, under the Cleaning Instruction for Ice-O-Matic CIM Series Ice Machines section, showed the following:

-Proper cleaning of an ice machine requires two parts: descaling and sanitizing. Descaling should be scheduled at a minimum twice per year but no more than once a month;

-Descaling dissolves the mineral deposits on the evaporator and other surfaces. It removes scale, calcium, lime scale and other mineral buildup. Ice-O-Matic requires nickel safe cleaner such as Nu-Calgon Nickel-Safe Ice Machine Cleaner or equivalent diluted per manufacturer's instruction;

-Sanitizing should be performed after each descaling but no more than once per month. Sanitizing disinfects

the machine and removes microbial growth including mold and slime. Ice-O-Matic requires a nickel-safe sanitizer such as Nu-Calgon IMS-III or equivalent diluted per manufacturer's instructions;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0908 -Measure the appropriate amount of descaler according to the machine size and sump volume from chart.

The manual showed a chart for different Ice-O-Matic model numbers, sump size gallons, and examples of Level of Harm - Minimal harm or descaler concentration ratio of five fluid ounce per one gallon of water (or 39 ml per one liter of water), and potential for actual harm the sanitizer concentration ratio of 1.6 fluid once per one gallon of water (12.5 ml per one liter of water) and to add more according to the ice machine model; and Residents Affected - Few -Sanitizing the ice machine is recommended after descaling. Repeat the process with sanitizer at correct ratio.

Review of the facility's P&P titled Ice Machine - Operation and Cleaning revised date 10/1/14, showed the following:

-Wash the inside of the machine using pot and pan washing solution and rinse well;

-Sanitize the inside of the machine using a sanitizing solution and a clean cloth;

-Allow the inside of the machine to air dry, then refill the machine with ice; and

-Maintenance staff will clean the ice making mechanism according to manufacturer's guidelines.

Review of the facility's document titled Preventative Maintenance Ice Machine for 2024 showed an outside vendor performed the quarterly cleaning service on 4/29/24.

On 6/4/24 at 0803 hours, an inspection of the ice machine and concurrent interview and facility document

review was conducted with the Director of Maintenance. The upper inside cabinet layer of the ice machine was wiped with a white paper towel and a yellowish slime was observed on the paper towel. The Director of Maintenance verified the above finding. When asked how often the ice machine was cleaned and sanitized,

the Director of Maintenance stated he cleaned and sanitized the ice machine monthly, and quarterly by an outside vendor. When asked how he cleaned and sanitized the ice machine, the Director of Maintenance stated he removed the front panel of the ice machine covering the area where the ice was made, and the ice storage bin door. When asked what solution he used to clean the ice machine, the Director of Maintenance stated he used a capful of the nickel-safe ice machine cleaner (using the bottle cap) diluted with a little bit of water, to which he showed a bottle of H.B. 30 nickel safe ice machine cleaner. Upon inspection of the bottle of H.B. (Hydro Balance) 30 nickel safe ice machine cleaner, the directions for use section, showed to add H. B 30 to circulating water at the rate of three to six ounces per gallon of water. When asked what he used to sanitize the ice machine, the Director of Maintenance stated he used hot water to clean the inside of the ice machine and used the sanitizer spray only to the panels of the ice machine, to which he showed a green spray bottle. Upon inspection of the green spray bottle, the spray bottle was labeled only with for ice machine only sticker, and the spray bottle did not show any brand, nor a label to show if it was the correct sanitizer solution for the ice machine. The Director of Maintenance stated the green spray bottle was provided by the outside vendor but did not know what brand it was. The Director of Maintenance verified he did not follow the correct procedure and correct ratio of the solutions per the manufacturer's specifications, and per the facility's P&P.

39683

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0908 2. Review of the facility's P&P titled P-NP16 Blood Glucose Monitoring reviewed 4/27/23, showed a glucometer quality control check will be performed at least once every 24 hours, and to document the results Level of Harm - Minimal harm or in the quality control log. potential for actual harm

Review of the facility's Order List Report for Medication Cart A dated 6/6/24, showed three residents had Residents Affected - Few routine glucometer checks.

On 6/4/24 at 1416 hours, an inspection of the Medication Cart A was conducted with LVN 1. Review of the glucometer Quality Control Record for June 2024, showed the daily Quality Control (QC) testing was completed for a glucometer machine with the serial number 1040-425000016. However, the Assure Platinum glucometer machine stored in the medication cart showed a serial number 1040-4039524. LVN 1 verified the serial numbers for the glucometer machine in the medication cart did not match the serial number in the control log. LVN 1 stated it should match.

On 6/6/24 at 0836 hours, an interview was conducted with the DON. The DON stated the glucometer serial number on the QC log should match the glucometer machine serial number in the medication cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39670

Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the residents' entrapment assessments were accurate, complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with

the use of bed rails for all three residents (Residents 18, 50, and 423) with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Findings:

According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space

in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.

The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:

- Zone 1: within the rail;

- Zone 2: under the rail, between the rail supports or next to a single rail support;

- Zone 3: between the rail and the mattress;

- Zone 4: under the rail, at the ends of the rail;

- Zone 5: between split bed rails;

- Zone 6: between the end of the rail and the side edge of the head or foot board; and

- Zone 7: between the head or foot board and the mattress end.

Review of the facility's P&P titled Bed Rails revised 11/16/22, showed for the purpose of this policy bed rails include side rails, safety rails, and grab or assist bars. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattresses will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. Maintenance staff routinely inspects all bed and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspection to the administrator and report results to the QAPI committee for appropriate actions. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0909 Review of the facility documents showed the facility had three residents with the use of side rails.

Level of Harm - Minimal harm or A concurrent observation, medical record review, and facility document review for Residents 18, 50, and 423 potential for actual harm showed the residents' bed entrapment assessments were not accurate, completed, or the bed inspection gap measurements were not recorded from bed to side rail or bed headboard to siderail. For example: Residents Affected - Few 1. On 6/3/24 at 1054 hours and 6/4/24 at 0819 hours, Resident 50 was observed lying in bed with both upper side rails were elevated.

Medical record review for Resident 50 was initiated on 6/4/24. Resident 50 was admitted to the facility on [DATE REDACTED].

Review of Resident 50's H&P examination dated 5/16/24, showed Resident 50 did not have capacity to understand and make decisions.

Review of Resident 50's Bed Rail assessment dated [DATE REDACTED], showed bilateral side rails were used for mobility and safety.

On 6/5/24 at 0920 hours, an interview for Resident 50 was conducted with CNA 7. CNA 7 verified Resident 50's use of upper side rails. CNA 7 stated the resident was able to hold the rails while providing care but unable to pull herself up.

2. On 6/3/24 at 1056 hours an 6/4/24 at 0958 hours, Resident 423 was observed in bed with both upper side rails elevated.

Medical record review for Resident 423 was initiated on 6/3/24. Resident 423 was admitted to the facility on [DATE REDACTED].

Review of Resident 423's Order Summary Report dated 6/4/24, showed a physician's order dated 5/29/24, for bilateral side rails for bed mobility and positioning.

Review of Resident 423's Bed Rail assessment dated [DATE REDACTED], showed bilateral side rails were used for mobility and safety.

On 6/5/24 at 1118 hours, an interview for Resident 423 was conducted with CNA 2. CNA 2 verified Resident 423's use of upper side rails. CNA 2 stated the resident was able to use the side rails for repositioning and turning.

On 6/4/24 at 1429 hours, an interview and concurrent facility document review for Resident 50 and 423 was conducted with the Maintenance Director. The Maintenance Director stated he was responsible to do the entrapment risk assessment of the facility's beds with side rails. The Maintenance Director stated he had the list of the beds with side rails assessed for entrapment. The Maintenance Director was able to show the blank Bed System Measurement Device Test Results Worksheet form. However, the Maintenance Director could not provide the documentation if the bed inspection and entrapment risk assessment were performed for the beds with side rail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0909 On 6/6/24 at 1046 hours, an interview was conducted with the DON. The DON was informed of the above findings and verified the findings. Level of Harm - Minimal harm or potential for actual harm 32179

Residents Affected - Few 3. Medical record review of Resident 18 was initiated on 6/3/24. Resident 18 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

Review of Resident 18's H&P examination dated 4/3/24, showed Resident 18 had fluctuating capacity to understand and make decisions.

Review of Resident 18's Bed Rail assessment dated [DATE REDACTED], showed the side rails or assist bars indicated and serve as an enabler to promote independence.

Review of Resident 18's Plan of Care dated 5/16/24, showed a care plan problem to address Resident 18 use of the bilateral upper quarter siderails for ADL changes, mobility, positioning and as an enabler. The interventions included to discuss and record with the resident family or caregivers the risk and benefits of the restraint when the restraints should or will be applied, the routines while restrained, and any concern or issues regarding restraint issues.

On 6/3/24 at 0910 hours and 6/3/24 at 1215 hours, Resident 18 was observed lying in bed with the bilateral upper bed rails elevated (from head to elbow).

On 6/4/24 at 1430 hours, an interview and concurrent record review for Residents 18 was conducted with the Maintenance Director. The Maintenance Director stated he was responsible for the bed inspection including inspecting, and installing the bed rails after he received the request from the nurses to install the bed rails.

The Maintenance Director was asked to provide documentation for entrapment assessment. The Maintenance director acknowledged he did not do any entrapment assessment. The maintenance Director verified the above findings.

On 6/6/24 at 1100 hours, the Environmental Services Staff was summoned to Resident 18's room. The Environmental Services Staff measured the side rail length and width and it was 20.5 inches by 10 inches.

The Environmental Services Staff acknowledged that the gap with length and width of 3 inch x 7 inch could possibly entrapped the arm and hand. The Environmental Services Staff verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 056362

F-F813.

3. On 6/4/24 at 0803 hours, an ice machine inspection, concurrent interview, and facility document review was conducted with the Director of Maintenance. The upper inside cabinet layer of the ice machine was wiped with a white paper towel and a yellowish slimy residue was observed on the paper towel. The Director of Maintenance verified the above findings. When asked what solutions were used to clean the ice machine,

the Director of Maintenance stated he used two solutions, to which he showed a bottle of Hydro Balance H. B. 30 ice machine cleaner nickel-safe, and a green bottle and labeled only with for ice machine only.

Cross-reference to

F-F908.

4. According to DA Food Code 2022, 4-602.13, Non-Food Contact Surfaces, showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

Review of the facility's P&P titled Hood and Filter-Operation and Cleaning dated 10/1/14, showed the hood and filter system will be cleaned routinely at least weekly or more often as necessary, and hoods will be kept free of grease and dust.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 On 6/3/24 at 0805 hours, during an initial tour of the kitchen, a brownish black residue was observed on the hood vent, a teardrop-shaped brownish liquid was observed on the cable part of the hood, and a brownish Level of Harm - Minimal harm or residue was observed on the tube sticking out of the hood. The DSS verified the above findings. The DSS potential for actual harm stated the hood/vent system deep cleaning was scheduled every six months by an outside vendor, and the hood/ vent system was last cleaned on December 2023. Residents Affected - Few 5. According to FDA Food Code 2022, 4-601.11, Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils, showed the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of

an accumulation of dust, dirt, food residue, and other debris.

On 6/3/24 at 0805 hours, during the initial tour of the kitchen, the following was observed:

-A black residue was observed on the bottom oven;

-Several food debris and pieces of aluminum foil were observed underneath the oven;

-Several food debris were observed on the inner bottom of the heated plate dispenser; and

-Several food debris were observed on the blender machine.

The DSS verified the above findings.

6. According to FDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, showed after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before contact with food.

According to FDA Food Code 2022, 4-903.11, Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, showed cleaned equipment and utensils shall be stored in a self-draining position that allows air drying.

a. On 6/3/24 at 0805 hours, during the initial tour of the kitchen, the blender container was observed stored with water residue inside the container. The DSS verified the above finding.

b. On 6/4/24 at 1029 hours, a pureed food observation was conducted with [NAME] 1, with the DSS present.

After pureeing the beef, a dietary staff was observed taking and washing the blender container and measuring cup. [NAME] 1 was observed taking the blender container and measuring cup and was observed using a paper towel to dry the blender container and measuring cup. [NAME] 1 and the DSS verified the above findings.

7. According to FDA Food Code 2022, Section 4-501.12, Cutting Surfaces, showed surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.

On 6/5/24 at 0805 hours, two green cutting boards were observed to be heavily marred with knife marks. The DSS verified above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453 potential for actual harm Based on observation, interview, medical record review, and facility P&P review, the facility failed to follow Residents Affected - Few the P&P for the resident's food brought by the visitors for one of 18 final sampled residents (Resident 58).

* The facility failed to ensure the safe food handling guidelines were implemented to the resident's family/visitors who brought the resident food from the outside. In addition, the facility failed to provide resident and family with the P&P about the use and storage of brought in by family and visitors as part of their admission packet as per the facility's P&P.

These failures had the potential for unsafe food handling and may cause foodborne illness to the residents who received food brought by the visitors.

Findings:

Review of the facility's P&P titled Food Brought In by Visitors revised 6/2018 showed when food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose, and provide resident and family with the P&P about the use and storage of brought in by family and visitors as part of their admission packet.

On 6/5/24 at 1131 hours, several fruits and unlabeled food containers were observed on the resident's bedside table, overbed table, floor, and on the bed.

Medical record review for Resident 58 was initiated on 6/3/24. Resident 58 was readmitted to the facility on [DATE REDACTED].

Review of Resident 58's plan of care dated 5/17/24, showed a care plan problem to address family and resident bringing extra food from home and keeps under the bed, bedside drawer and bedside table. The interventions included to provide education to resident and family regarding infection control, to continue to communicate to resident and family about bringing extra food at bedside, and to continue to offer the resident bridge as a form of storage.

Review of Resident 58's Progress Notes dated 5/17/24 at 1505 hours, showed the MDS Coordinator called Resident 58's family member regarding extra food at bedside including the drawers, table, and under the bed, informed about extra food at bedside was bed stored in containers with lid for infection prevention purposes, and offered resident refrigerator as means of storage.

Further review of Resident 58's medical records did not show the staff continued to communicate to resident and family about bringing and storing the extra food. Further review, there was no documentation to show follow-up regarding family members bringing and storing the extra food for Resident 58.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 056362 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056362 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

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 0813 On 6/5/24 at 1203 hours, an observation and concurrent interview was conducted with CNA 2. Several fruits and unlabeled food containers were observed on the resident's bedside table, overbed table, floor, and on Level of Harm - Minimal harm or the bed. CNA 2 verified the above findings. CNA 2 stated the facility was aware of the food containers, and potential for actual harm fruits brought in by the resident's family members.

Residents Affected - Few On 6/5/24 at 1211 hours, an interview and concurrent medical record review for Resident 58 was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 stated the MDS Coordinator spoke with Resident 58 and her family members.

On 6/5/24 at 1218 hours, an interview and concurrent medical record review for Resident 58 was conducted with the MDS Coordinator. The MDS Coordinator stated she called Resident 58's family member regarding extra food at bedside. The MDS Coordinator stated during the last visit of Resident 58's family member, he stated he would bring food container. When asked if she conducted a follow-up, the MDS Coordinator verified she did not follow-up with the family members bringing and storing the extra food for Resident 58.

On 6/6/24 at 1018 hours, an interview and concurrent medical record review for Resident 58 was conducted with the Admissions Director. When asked if she communicated to the residents or their family members,

during admission, regarding bringing in food from outside, the Admissions Director stated she would only communicate regarding bringing in food from outside to the resident or the family members only if the resident or family members asked about it. When asked if the policy about the use and storage of brought in by family and visitors was provided to the residents or their representative as part of their admission packet,

the Admission Director stated the policy should be part of their admission packet. When asked for a documentation of the policy about the use and storage of brought in by family and visitors provided to Resident 58 and/ or representative, the Admission Director showed Resident 58's Admission Agreement.

Review of Resident 58's Admission Agreement dated 2/22/23, under Attachment G: Snacks, showed to make sure all food or snacks left with the resident are stored in a sealed Tupperware-like container. The charge nurse must be notified in advance of any meals that will be brought in for the resident.

Further review of Resident 58's Admission Agreement, and admission packet, did not show the policy about

the use and storage of brought in by family and visitors was provided to Resident 58 and/ or representative, as part of the admission packet.

The Admissions Director verified the above findings.

Cross-reference to