Inspection·May 1, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for two of two sampled residents (Residents1 and 2) and one nonsampled resident (Resident D). * Resident 2's bubble pack of metformin (medication to treat diabetes) medication was found hidden in Resident 1's closet for 10 days. * Resident D's side table drawer had a medication cup filled with thick white cream and a tongue depressor. These failures had the potential to result in the unauthorized access to the medications and impact the residents' safety. Findings: Review of the facility's P&P review titled Medication Storage in the Facility revised 1/2025 showed the following: a. Medication and biologicals are stored safely, securely, and properly, following manufacture's guidelines or those of the supplier. The medical supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. b. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. 1.a. Medical record review for Resident 1 was initiated on 4/16/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 had a diagnosis of DM Type 2. Review of Resident 1's H&P examination dated 8/30/20, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report for April 2025 showed an order dated 2/4/25, for metformin 500 mg oral tablet, give one tablet by mouth two times a day. b. Medical record review for Resident 2 was initiated on 4/16/25. Resident 2 was admitted to the (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 2 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 05/01/2025 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)