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 (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 08/29/2025 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)