Health inspection·August 29, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **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 report and investigate a resident-to-resident altercation to the State Survey Agency in accordance with the state law established procedures for two of five sampled residents (Residents 1 and 4). * Resident 1 stated a male resident (Resident 4) walked into her room unsupervised, screamed and threatened her. The incident was not reported to the appropriate parties (CDPH, the Ombudsman, the residents' responsible parties, the MD and the police department) nor was an investigation initiated. This failure had the potential to negatively impact the well-being of the resident of the facility. Findings: Review of the facility's P&P titled Abuse Prevention and Management revised 5/2024 showed the facility will report all allegation of abuse, and criminal activity as required by law and regulations to the appropriate agencies. The P&P also stated to address the health, safety, welfare, dignity and respect of residents, the reports of resident abuse, mistreatment, neglect, exploitation, injuries of an unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. Review of the facility's P&P titled Unusual Occurrence Reporting revised 5/2024 showed the facility will follow all applicable, state and federal laws and regulations regarding the reporting of unusual occurrences. On 8/16/25 at 0930 hours, the CDPH L&C Program received a complaint alleging Resident 1 stated a male resident walked into her room unsupervised on 8/16/25. Resident 1 alleged the male resident screamed and threatened her, making her feel very unsafe. Resident 1 called her family member to pick her up and take her home. On 8/29/25 at 0638 hours, an interview was conducted with RN 1. RN 1 stated Residents 1 and 3 were roommates. RN 1 further stated Resident 3's Family Member informed him Resident 4 wandered to Residents 1 and 3's bedroom. RN 1 stated Resident 1 did not feel comfortable and went home that evening. a. Closed medical record review for Resident 1 was initiated on 8/29/25. Resident 1 was admitted to the facility on [DATE], and discharged on the same day. Resident 1 was alert, and oriented to time, place and persons by the admitting nurse. Review of Resident 1's medical record failed to show documented evidence of the incident. In addition, there was no documentation the incident was reported to the CDPH, Ombudsman, residents' responsible parties, MD, and the police department were notified. b. Medical record review for Resident 4 was initiated on 8/29/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed a BIMS score of 3 (meaning severe cognitive impairment.) Further review of Resident 4's medical record failed to show documented evidence of the incident with Resident 1. There was no documentation of the resident's wandering episode and verbal outbursts towards Resident 1 on 8/16/25. On 8/29/25 at 0824 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she witnessed Resident 4 enter Resident 1's room. RN 2 stated she redirected and reoriented Resident 4 out of the room. RN 2 further stated Resident 1 requested to be discharged AMA after the incident. RN 2 informed the Administrator of Resident 1's request to discharge AMA, and of Resident 4's Page 1 of 2 056362 056362 08/29/2025 Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 056362 Page 2 of 2