Mesa Verde Post Acute Care Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
wandering episode to Resident 1's room. RN 2 verified, there was no written documentation of the incident
in either Residents 1 and 4's medical records to address Resident 4's wandering behavior to Resident 1's room and Resident 1's response to Resident 4's wandering to her room. RN 2 verified she should have documented the incident. On 8/29/25 at 1101 hours, a telephone interview was conducted with Resident 1.
Resident 1 stated on the day of admission, 8/16/25, a man in a wheelchair (later identified as Resident 4) suddenly entered her room, yelled and screamed toward Resident 1's direction. Resident 1 stated Resident 4 was screaming I'm gonna kill someone. she's raping my wife and what is she doing here. Resident 1 stated a nurse immediately entered and redirected the resident back to his room. However, Resident 4 reportedly returned to Resident 1's room three times in 20 minutes, toppled over the overbed table by Resident 1's bedside and continued to scream at Resident 1. Resident 1 further stated I was shaking and hysterically crying. Resident 1 stated she didn't trust the facility when she was offered another room by nurse. Resident 1 further stated Resident 3's Family Member assisted the staff in removing Resident 4 out of the room. Resident 1 decided to discharge from the facility AMA that same evening. On 8/29/25 at 1142 hours, an interview and concurrent medical record review for Resident 1 was conducted with the MDS Coordinator. The MDS Coordinator verified the resident-to-resident altercation on 8/16/25, was not documented, nor was there an incident report. On 8/29/25 at 1215 hours, an interview was conducted with Resident 3 and Family Member 1. Resident 3 and Family Member 1 stated Resident 4 came into their room
in his wheelchair and yelled I wanna kill somebody. Resident 3 stated it was very frightening. Family Member 1 stated Resident 4 came back a second and third time to get into Resident 1's bed. Resident 4 kept screaming I wanna kill somebody. Resident 3 stated Resident 1 was freaking out, scared to death, crying and decided to discharge AMA. Family Member 1 stated he assisted the staff in removing Resident 4 from their room. On 8/29/25 at 1230 hours, an interview and concurrent medical record review was conducted with the Administrator. The Administrator stated he received a call on 8/16/25, from RN 2 reporting Resident 1 requested to be discharged AMA, and Resident 4 wandered to Resident 1's room. The Administrator stated he was not aware Resident 4 was difficult to redirect and was screaming at Resident 1.
The Administrator stated if he knew the incident was serious, he would have investigated it. The Administrator verified the resident-to-resident altercation was not investigated nor reported to the CDPH L&C Program.
Event ID:
Facility ID:
If continuation sheet
MESA VERDE POST ACUTE CARE CENTER in COSTA MESA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COSTA MESA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MESA VERDE POST ACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.