Inspection·November 27, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to obtain the appropriate consent prior to administering the COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) and influenza vaccines for one of two sampled residents (Resident 1). This failure had the potential to result in the resident receiving the vaccines without the resident's responsible party being informed of the risks, benefits, and side effects prior to administering the vaccines. Residents Affected - Some Findings: Medical record review for Resident 1 was initiated on 11/27/24. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 8/30/24, showed the resident had no capacity, and the resident's family member was the surrogate decision maker. Review of Resident 1's Durable Power of Attorney for Healthcare dated 3/11/21, showed the resident named Family Member 1 as his designated healthcare decision maker, effective immediately. Review of Resident 1's Informed Consent for Immunizations dated 10/9/24, showed Resident 1 signed the consent form to consent for the administration of the COVID-19 and influenza vaccines. Review of Resident 1's MAR for October 2024 showed on 10/16/24, the COVID-19 and influenza vaccines were administered to the resident. On 11/27/24 at 1228 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Family Member 1 was Resident 1's responsible party and verified the facility failed to inform and obtain the consent from Family Member 1 prior to administering the COVID-19 and influenza vaccines to Resident 1. 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 11/27/2024 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)