Inspection·July 16, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure to coordinate the effective discharge planning process when the SSD failed to communicate to the IDT the development of the discharge plan and failed to document in the resident's medical record regarding the evaluation of the ALF waiver process. Additionally, the facility failed to notify the resident's family member about the ALF waiver was denied for one of six sampled residents (Resident 4). These failures had the potential to affect the resident's well-being after discharge. Findings: On 7/11/25 at 1702 hours, prior to the onsite investigation, a telephone interview was conducted with Family Member 2. Family Member 2 stated the facility's SSD had informed her Resident 4 will have the ALF waiver for continued care in the ALF after discharge from the SNF. However, the resident needed to pay in the ALF because the waiver was not approved. Closed medical record review for Resident 4 was initiated on 7/15/25. Resident 4 was admitted to the facility on [DATE], and was discharged on 6/6/25. Review of Resident 4's H&P examination dated 4/5/25, showed the resident was unable to make medical decisions. Review of Resident 4's MDS assessment dated [DATE], showed the resident's BIMS score was 5 which meant the resident had moderate cognitive impairment. Resident 4's overall goal for discharge was to discharge to the community. Review of Resident 4's medical record showed a Multidisciplinary Care Conference was held on 4/15/25. However, the medical record failed to show a discharge planning was discussed with Resident 4 or the resident's family member. Review of Resident 4's Social Services Progress Note dated 6/3/25 at 1555 hours, showed Resident 4 would be moving to the ALF pending the ALF waiver and get it expedited. Review of Resident 4's Order Summary Report showed a physician's order dated 6/6/25, to discharge the resident to the ALF with home health, physical therapy, occupational therapy, and RN services. Review of Resident 4's Notice of Medicare Non-Coverage showed the Medicare coverage of resident's skilled nursing services will end on 6/4/25. The Confirmation of Notice by telephone showed Resident 4's Family Member 2 was contacted on 6/5/25 (the time of the notification was not documented) signed by the SSD in SNF representative on 6/5/25. A mail confirmation of the follow-up notice was sent on 6/5/25. Review of Resident 4's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage showed beginning on 6/5/25, the resident may have to pay out of pocket for the care received during the in patient for the skilled nursing services care including physical therapy, occupational therapy, and daily skilled nursing care due to resident's/family choice to discharge on [DATE]. The Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form failed to show for a signature of the resident or resident's authorized representative. On 7/15/25 at 1353 hours, an interview and concurrent closed medical record review for Resident 4 was conducted with the SSD. The SSD stated the previous SSD was not working in the facility any longer. The SSD stated she started as the facility's SSD last week. The SSD stated the IDT should have met periodically regarding resident's discharge process and updated the team with regards to the discharge planning, (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 07/16/2025 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)