Mesa Verde Post Acute Care Center

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.

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