Inspection·March 12, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of two sampled residents (Residents 1 and 2) when Residents 1 and 2's controlled drug records and MARs were not maintained to ensure the accuracy reconciliation of the narcotic pain medications. * Resident 1's oxycodone HCl (narcotic pain medication) Individual Drug Record sheet did not match Resident 1's MAR. The oxycodone HCL was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. * Resident 2's hydrocodone-acetaminophen (narcotic pain medication) Individual Drug Record sheet did not match Resident 2's MAR. The hydrocodone-acetaminophen medication was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. These failures posed the for risk of diversion of the controlled medications. Findings: According to the facility's P&P titled Preparation and General Guidelines for Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): a. Date and time of administration; b. Amount administered; c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply; and d. Initials of the nurse administering the dose on the MAR after the medication is administered. 1. Review of Resident 1's medical record was initiated on 3/7/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 1/30/24, showed a physician's order dated 12/29/23, to administer oxycodone HCl 10 mg by mouth every four hours as needed for severe pain. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056362 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056362 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 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)