Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mesa Verde Post Acute Care Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
Medications were not securely stored as required, with one resident's diabetes medication found hidden in another resident's closet for several days after being taken by a CNA, and another resident's prescribed zinc oxide cream left in a bedside drawer. These actions violated facility policy and resulted in unauthorized access to medications.
A resident with type two diabetes mellitus was improperly discharged from the facility without necessary documentation and communication. The discharge planning indicated the resident would have a caregiver, but the facility failed to provide a discharge/transfer report, including evidence of teaching or training for the resident and caregiver. Interviews revealed that the discharge protocol was not followed, as no education or training was provided, and the caregiver was not present or contacted during the discharge.
A resident was discharged with home health services, but the facility failed to document a referral to a home health agency, risking the resident's post-discharge care. The order included follow-up by home health PT/OT/RN and a PCP visit, but no referral documentation was found. The SSD discussed the discharge with the resident but could not provide evidence of the referral, which was acknowledged by the Administrator and DON.
A facility administered COVID-19 and influenza vaccines to a resident without obtaining consent from the designated surrogate decision maker, despite the resident lacking capacity to make healthcare decisions. The resident's family member was the authorized decision maker, but the facility failed to inform them or obtain their consent prior to vaccination.
The facility failed to maintain accurate medical records for two residents. One resident's decision-making capacity entry was improperly corrected without a date or initials. Another resident's fall was not accurately documented in their LTC Evaluation note, despite being recorded in a Post Fall Evaluation. These discrepancies were confirmed by the DON.
The facility failed to assess two residents for the ability to self-administer medications. One resident self-administered insulin without a physician's order or care plan documentation, despite an assessment indicating they were not capable. Another resident was ordered to self-administer an antibiotic without proper assessment, despite fluctuating decision-making capacity. Staff were unaware of the lack of documentation supporting these actions.
The facility failed to ensure call lights were within reach and responded to in a timely manner for several residents. Residents were found with call lights on the floor, out of reach, and reported long wait times for assistance, particularly during night shifts. These issues were verified by staff and posed risks to residents' well-being.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident with a CVAD for IV antibiotic treatment lacked a care plan for its use, confirmed by the RN and DON. Another resident, requiring a cervical collar and TLSO brace, did not have a care plan addressing their application and noncompliance, with staff unaware of the resident's refusal to comply.
A resident who required a cervical collar after being hit by a car was not wearing it as ordered by the physician. The facility's staff, including the DOR, RNA, and LVNs, were unaware or did not act on the physician's order, and the resident's non-compliance was not documented or addressed. The DON and MDS Coordinator confirmed the oversight and lack of follow-up with an orthopedic specialist.
A resident was found to have cigarettes stored in their room, contrary to the facility's policy requiring secure storage of smoking materials. Despite the care plan indicating that smoking materials should be stored in a designated box, staff allowed the resident to keep them in their room. This posed a risk of fire and serious injuries to other residents.
A resident with a suprapubic catheter and recurrent UTIs was found with a urinary drainage bag on the floor, posing a risk for CAUTI. The resident admitted to placing the bag on the floor and was not educated by the facility about the risks. Staff confirmed the improper positioning and acknowledged the need for proper catheter care.
The facility failed to provide proper respiratory care for four residents by not labeling nasal cannulas and improperly storing nebulizer and CPAP masks. Staff confirmed these deficiencies, which were not in line with the facility's policies requiring proper storage and labeling of respiratory equipment.
A resident requiring dialysis care did not receive proper assessment and monitoring of their dialysis access site upon returning from the dialysis clinic. The facility's staff failed to conduct and document necessary assessments, as required by the facility's policy, leading to a deficiency in care.
The facility failed to document the administration of controlled pain medications for two residents, as required by their policy. An LPN confirmed that the medications were removed but not recorded in the MAR, indicating a lapse in pharmaceutical services.
A facility failed to act on a Pharmacy Consultant's recommendation for a resident's medication regimen. The resident was prescribed buspirone for anxiety, but the Consultant noted that the diagnosis was too subjective and recommended a specific behavior be documented. There was no evidence that the physician was notified or that the recommendation was acted upon. An RN claimed to have followed up with the physician but could not provide documentation.
The facility failed to remove expired medications from two medication carts. In Medication Cart B, expired vials of injectable sterile water were found, confirmed by an RN. In Medication Cart A, an open package of budesonide inhalation solution past its use-by date was discovered, verified by an LVN. This oversight violated the facility's policy on medication storage, risking the administration of expired medications to residents.
The facility did not adhere to menu and portion control guidelines, impacting residents' nutritional needs. The cook deviated from the recipe for pureed Spinach Au Gratin by omitting margarine and cheese, and used a #12 scoop instead of the required #8 scoop for serving, leading to incorrect portion sizes. These issues were confirmed by the DSS during observations and interviews.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as improper labeling and dating of food, unsanitary kitchen equipment, and inadequate air drying of utensils. Observations included unlabeled frozen foods, a dirty ice machine, and marred cutting boards, all of which could lead to foodborne illnesses among residents.
A facility failed to follow its policy on food storage brought by visitors for a resident. Unlabeled food containers were found in the resident's room, and the facility did not provide the resident and family with the policy guidelines as part of the admission packet. Staff interviews confirmed awareness of the issue but showed a lack of consistent communication and enforcement of the policy.
The facility failed to properly dispose of trash, as one of three dumpsters was found overflowing with boxes, preventing the lid from fully closing. This was confirmed by the Director of Maintenance, violating FDA Food Code 2013, 5-501.113, which requires waste receptacles to be covered with tight-fitting lids.
The facility failed to maintain confidentiality and accuracy in resident records. Confidential resident rosters were mistakenly included in a publicly accessible binder, and a resident's weight was inaccurately recorded due to a unit conversion error. The Administrator and DON confirmed these errors during interviews.
The facility failed to implement proper infection control practices, as observed when a CNA placed briefs and blue chucks on an isolation cart for distribution, risking contamination and infection spread. The CNA acknowledged the inappropriate handling of these items.
The facility failed to maintain essential equipment safely, with improper cleaning and sanitizing of the ice machine and mismatched serial numbers for the glucometer. The ice machine was not cleaned per manufacturer guidelines, and the glucometer's serial number did not match the quality control log, posing risks to resident safety.
The facility failed to conduct accurate and complete entrapment assessments for residents using bed rails, risking potential entrapment and injury. Observations showed residents with elevated side rails, but the maintenance director could not provide documentation of bed inspections or entrapment risk assessments. Measurements revealed gaps that could entrap a resident's arm or hand, confirming deficiencies in the facility's bed inspection process.
A facility failed to provide necessary GT care for a resident when the tube feeding bottle label lacked the start time and nurse's initials. Observations revealed non-compliance with the facility's policy, which required labeling with specific details. Interviews with staff confirmed the oversight, and the resident, who lacked decision-making capacity, had a physician's order for Jevity 1.2 feeding formula. This failure posed potential risks for complications and infections.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Medications Improperly Stored and Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and not kept at the bedside, as required by facility policy and professional standards. In one instance, a bubble pack of metformin prescribed for a resident with diabetes was found hidden in another resident's closet for ten days. The investigation revealed that a CNA, who also had diabetes, took the medication from the medication room when the door was left slightly open and hid it in the resident's room with the intention of taking it home, but forgot about it until it was discovered by the resident's family. The resident whose closet was used to hide the medication had no capacity to understand or make decisions, as documented in their medical record. Additionally, another resident's side table drawer was found to contain a medication cup filled with thick white cream and a tongue depressor, which the DON identified as zinc oxide cream prescribed for a pressure injury. This medication was not stored securely as required. Both incidents were acknowledged by facility leadership and were in direct violation of the facility's medication storage policy, which mandates that medications be accessible only to authorized personnel and not stored at the bedside.
Improper Discharge Process for a Resident with Diabetes
Penalty
Summary
The facility failed to ensure a proper discharge process for Resident 1, who was diagnosed with type two diabetes mellitus with hyperglycemia. The resident was discharged without the necessary documentation and communication of critical information. The discharge planning review form indicated that the resident was going home with a friend and would have a caregiver after discharge. However, the facility could not provide the discharge/transfer report, which should have included evidence of teaching or training provided to the resident and the caregiver, as well as a list of medications. Interviews with LVN 1 and the DON revealed that the discharge protocol was not followed. LVN 1 confirmed that no teaching or training was provided to the resident or the caregiver, and the caregiver was not present or contacted during the discharge. The DON acknowledged that Resident 1 required assistance with medication administration and could not self-administer insulin injections. The DON confirmed that the discharge was unsafe due to the lack of education and training provided to the resident and caregiver, and the absence of the responsible person during the discharge.
Failure to Document Home Health Referral for Discharged Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for Resident 1, who was discharged with home health services. The medical record review revealed that there was no documentation indicating that a referral to a home health agency was arranged prior to the discharge. This oversight placed Resident 1 at risk of not receiving the necessary care after leaving the facility. The Order Summary Report for Resident 1 included an order for discharge to home with current medications and follow-up by home health PT/OT/RN, with a subsequent follow-up with the PCP in one to two weeks. A progress note indicated that the SSD had discussed the discharge with Resident 1 and intended to arrange home health services as ordered. However, further review of the medical record did not show evidence of a referral being sent to the home health provider. During an interview, the SSD was unable to provide documentation for the home health services referral, and the Administrator and DON acknowledged these findings.
Failure to Obtain Proper Consent for Vaccination
Penalty
Summary
The facility failed to obtain the appropriate consent prior to administering COVID-19 and influenza vaccines to a resident who lacked capacity to make healthcare decisions. The resident, who was readmitted to the facility, had a family member designated as the surrogate decision maker according to a Durable Power of Attorney for Healthcare. Despite this, the resident personally signed the informed consent for immunizations, which was not valid due to their lack of capacity. The vaccines were administered without the consent of the designated family member. During an interview, the Director of Nursing confirmed that the facility did not inform or obtain consent from the resident's responsible party before administering the vaccines.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential care issues. For the first resident, the History and Physical examination document had a section where a decision-making capacity entry was struck through without a date or initials, making it unclear when and by whom the correction was made. This lack of proper documentation could lead to misunderstandings about the resident's ability to make medical decisions. For the second resident, there was a discrepancy in the medical records regarding a fall. The resident experienced an unwitnessed fall, which was documented in a Post Fall Evaluation note. However, a subsequent Long Term Care Evaluation note incorrectly stated that the resident had not experienced any falls since the last evaluation. This error was confirmed by the DON, who acknowledged that the record should have reflected the fall, indicating a failure in maintaining accurate records.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the ability to self-administer medications, as evidenced by the cases of two residents. Resident 23 was observed self-administering insulin without a physician's order permitting self-administration, and the resident's care plan did not document the ability to self-administer medications. Despite the resident's history and physical examination indicating the capacity to understand and make decisions, the most recent assessment showed the resident was not capable of self-administering subcutaneous injections, and all medications were to be administered by a nurse. LVN 1, who was responsible for the resident's care, was unaware of the lack of documentation supporting the resident's ability to self-administer insulin. Similarly, Resident 18 was not assessed for the ability to self-administer medications, despite a physician's order for unsupervised self-administration of an antibiotic. The resident's history indicated fluctuating capacity to understand and make decisions, and the assessment showed that all medications were to be administered by a skilled nurse. RN 1 confirmed that the resident was not capable of self-administration and acknowledged the transcription of the physician's order into the MAR, which had the potential for the resident to self-administer the antibiotic without proper assessment or documentation.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to promote dignity and respect for several residents by not ensuring that call lights were within reach and not responding to call lights in a timely manner. Specifically, Residents 18, 22, and 62 were observed with their call lights on the floor, out of reach, which prevented them from calling for assistance when needed. This was verified by staff members who acknowledged the issue. Resident 18, who had limited mobility and quadriplegia, was unable to reach the call light, and this was confirmed by an LVN. Similarly, Resident 22, who had multiple health issues including dementia and impaired communication, was also found with the call light on the floor, as verified by another LVN. Additionally, the facility did not ensure timely responses to call lights for Residents 4, 23, and 60. Resident 4 reported that staff would hide the call light during the night shift and that there were instances where the call light was turned off without attending to her needs. This resident, who was dependent on staff for toileting hygiene, expressed concerns about waiting over an hour for assistance. Resident 23, who required moderate assistance, also reported long wait times during the night shift and mentioned that staff cited insufficient staffing as a reason for delays. Resident 60's family member corroborated these issues, stating that the resident had to wait for hours for assistance, which caused agitation due to incontinence. The facility's policy and procedure on the communication-call system, dated 1/1/12, stated that call cords should be within the resident's reach and that nursing staff should answer call bells promptly and courteously. However, the observations and interviews conducted during the survey revealed that these policies were not being followed, leading to deficiencies in the care provided to the residents. These failures posed a risk to the residents' physical and emotional well-being, as they were unable to receive timely assistance for their needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 423, who was admitted with a central venous access device (CVAD) for intravenous antibiotic treatment, did not have a care plan problem developed to address the use of the CVAD. This oversight was confirmed through interviews and medical record reviews with the RN and the Director of Nursing (DON), who verified the absence of a care plan for the CVAD. Similarly, Resident 17, who required a cervical collar and a thoracic-lumbar-sacral orthosis (TLSO) brace following an accident, did not have a care plan addressing the application and noncompliance with these devices. Despite physician orders for the use of these devices, the resident was observed not wearing them, and staff interviews revealed a lack of awareness and documentation regarding the resident's refusal to comply. The DON and MDS Coordinator acknowledged the absence of a care plan for Resident 17's needs and noncompliance.
Failure to Apply Cervical Collar as Ordered
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident who required a cervical collar (c-collar) as ordered by a physician. The resident, who had been hit by a car while in a wheelchair, was observed without the c-collar on multiple occasions. The physician's order specified that the c-collar should be worn at all times, but the resident was non-compliant with this order. The facility's plan of care did not address the application of the c-collar or the resident's noncompliance. Interviews with various staff members, including the Director of Rehabilitation (DOR), Registered Nurse Assistant (RNA), and Licensed Vocational Nurses (LVNs), revealed a lack of awareness and action regarding the resident's need for the c-collar. The DOR acknowledged the resident's non-compliance and the need for a follow-up with an orthopedic specialist, but there was no documented evidence of notifying the physician or specialist about the resident's refusal. The Director of Nursing (DON) and MDS Coordinator confirmed the findings and acknowledged that the resident had not been seen by an orthopedic specialist during their admission.
Failure to Securely Store Smoking Materials
Penalty
Summary
The facility failed to provide a safe environment free from potentially serious accident hazards for a resident who was reviewed for smoking. The facility's policy and procedure for smoking residents required the interdisciplinary team to develop an individualized plan of care for the safe storage and use of smoking materials. However, during an observation and interview, it was found that the resident had a box of cigarettes stored inside a bag on the ground in his room. The resident stated that he kept the cigarettes in his room because the facility would forget about them, despite the facility's policy that smoking materials should be securely stored. Further investigation revealed that the resident's plan of care included an intervention for cigarettes and a lighter to be stored in a designated box. However, both an LVN and an RN confirmed that the resident was allowed to keep his smoking materials in his room, contrary to the facility's policy. The RN acknowledged that the cigarettes should not have been kept in the resident's room and proceeded to store them in a locked container at the nurse's station. This oversight posed a risk of fire and serious injuries to the residents in the facility.
Improper Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent a urinary tract infection (UTI) for a resident with a suprapubic catheter and a history of recurrent UTIs. The deficiency was identified when the resident's urinary drainage bag was observed laying on the floor during an initial tour of the facility. This improper positioning of the drainage bag posed a risk for the resident to develop a catheter-associated urinary tract infection (CAUTI), as it allowed urine to potentially flow back into the bladder. The resident, who had the capacity to understand and make decisions, admitted to placing the urinary drainage bag on the floor himself and sometimes putting it in a trash bag. He stated that the facility did not educate him about the risks associated with placing the drainage bag on the floor. Observations and interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that the urinary drainage bag should not be placed on the floor for infection control reasons. The MDS Coordinator acknowledged the findings and confirmed the resident's history of recurrent UTIs and the need for proper catheter care.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as observed during a survey. For two residents, the nasal cannula was not dated or labeled, and the nebulizer mask was improperly stored. One resident's CPAP mask was not stored correctly, and another resident's nasal cannula was left on top of a wheelchair instead of being stored properly. These actions were not in compliance with the facility's policies and procedures, which require respiratory equipment to be stored in labeled bags and changed regularly. The medical records of the residents involved showed that they had various respiratory conditions requiring specific treatments, such as oxygen therapy and nebulization. Interviews with facility staff, including LVNs and the DON, confirmed the improper storage and labeling of respiratory equipment. The staff acknowledged the deficiencies and verified that the equipment should have been stored according to the facility's policies to ensure safe and sanitary conditions for the residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, identified as Resident 29, who required dialysis services. The deficiency was observed in the lack of proper assessment and monitoring of the resident's dialysis access site. Specifically, the licensed staff did not assess Resident 29's dialysis access site after returning from the dialysis clinic, nor did they document any assessment of the site upon the resident's return. This oversight was contrary to the facility's policy and procedure, which required licensed staff to inspect the dialysis access site for functionality and signs of complications, and to document pre- and post-dialysis assessments. Resident 29, who received dialysis on Tuesdays, Thursdays, and Saturdays, was observed with a dry dressing on the left upper arm dialysis access site, which should have been removed four hours post-dialysis for an accurate assessment. Interviews with LVN 3 and RN 1 confirmed that the necessary assessments were not conducted or documented. Additionally, a review of the resident's medical records revealed a lack of documentation regarding a post-dialysis assessment on a specific date, further indicating a failure to adhere to the required care protocols.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, specifically in the administration and documentation of controlled pain medications. For Resident 17, the Individual Narcotic Record indicated that an oxycodone 10 mg tablet was removed from the supply on May 23, 2024, at 1400 hours. However, this administration was not documented in the resident's Medication Administration Record (MAR) for May 2024. This discrepancy was confirmed during an interview and medical record review with LVN 1, who acknowledged the missing documentation. Similarly, for Resident 23, the Individual Narcotic Record showed that a Norco 5-325 mg tablet was removed on June 3, 2024, at 2140 hours, but this was not recorded in the MAR for June 2024. LVN 1 verified the removal of the medication and confirmed the absence of documentation on the MAR. The facility's policy and procedure for controlled medications require immediate documentation of administration details in both the accountability record and the MAR, which was not adhered to in these cases.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for a resident reviewed for unnecessary medications. The resident was admitted to the facility and had a physician's order to administer buspirone HCL, an antianxiety medication, for anxiety manifested by restlessness. The Consultant Pharmacist's Medication Regimen Review noted that agitation or restlessness was too subjective to be used as a diagnosis or behavior and recommended updating the order with a specific and quantifiable behavior. However, there was no documented evidence that the resident's physician was notified or that the Pharmacy Consultant's recommendation was acted upon. During an interview, an RN stated that she had followed up with the physician and changed the manifested behavior to resisting care, but was unable to provide documentation to support this claim.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure the removal of expired and potentially deteriorated medications from two of its three medication carts, specifically Medication Carts A and B. During an inspection of Medication Cart B, two 10 ml vials of injectable sterile water with past expiration dates were found. RN 1 confirmed the vials were expired and acknowledged they should have been removed. Similarly, an inspection of Medication Cart A revealed a box of budesonide inhalation solution with an open foil package containing two ampules, which should have been used within two weeks of opening. LVN 1 verified that the remaining medication should have been removed from the cart, as per the instructions on the medication box. These findings indicate a failure to adhere to the facility's policy and procedure for medication storage, which mandates the immediate removal and disposal of outdated or deteriorated medications. This oversight had the potential to result in the administration of expired or deteriorated medications to residents.
Failure to Follow Menu and Portion Control Guidelines
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion control guidelines, which could potentially impact the nutritional needs of the residents. During the preparation of pureed Spinach Au Gratin, the cook did not follow the recipe as outlined in the facility's documents. Instead of using margarine and cheese as specified, the cook boiled the spinach with soup base and added a thickener, omitting the required ingredients. This deviation from the recipe was confirmed during an observation and interview with the cook and the Dietary Services Supervisor (DSS). Additionally, the facility did not follow the portion control guidelines for serving Spinach Au Gratin. The facility's portion control chart specified using a #8 scoop for a 1/2 cup serving size, but the cook used a #12 scoop instead. This discrepancy was observed during a trayline inspection, where trays prepared for residents on regular and mechanical soft diets contained incorrect portion sizes. The DSS acknowledged the error and confirmed that the serving size did not match the facility's guidelines.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by several observations during a survey. Foods in the kitchen were not properly labeled and dated, which is a violation of the FDA Food Code 2022, Section 3-501.17. During an inspection, a bag of frozen egg omelets, cookies, donuts, and blueberries were found without opened dates inside Freezer #2. Additionally, the refrigerator designated for residents' food brought in from outside contained a box of chimichangas labeled with a resident's name and due date, but also had four unlabeled bags of ice. Unlabeled food containers and fruits were also found in a resident's room, indicating a lack of adherence to the facility's policy on food brought in by visitors. The facility's kitchen equipment and environment were not maintained in a sanitary condition. The ice machine was found with a yellowish slimy residue, and the kitchen exhaust hood had brownish black residue, which had not been cleaned since December 2023. The oven and heated plate dispenser were observed with food debris, and the blender machine had food debris as well. These conditions violate the FDA Food Code 2022, which requires non-food contact surfaces to be kept clean to prevent microorganism growth and pest harborage. Furthermore, the facility did not ensure proper air drying of kitchen items, as required by the FDA Food Code 2022. A blender container was found with water residue, and a dietary staff member was observed using a paper towel to dry a blender container and measuring cup after washing. Additionally, two green cutting boards were heavily marred with knife marks, making them difficult to clean and sanitize. These deficiencies in maintaining sanitary conditions in the kitchen had the potential to cause foodborne illnesses among the medically vulnerable resident population who consumed food prepared in the facility's kitchen.
Failure to Follow Food Storage Policy for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedures (P&P) regarding the handling and storage of food brought in by visitors for a resident. Specifically, the facility did not ensure that food containers brought by the resident's family were labeled with the resident's name and date received, nor were they stored in a designated refrigerator. Instead, several fruits and unlabeled food containers were observed on the resident's bedside table, overbed table, floor, and bed. The facility's P&P required that residents and their families be provided with guidelines about the use and storage of food brought in by visitors as part of their admission packet, which was not done in this case. The medical records for the resident indicated a care plan problem related to the storage of extra food brought from home, with interventions including education on infection control and offering storage solutions. However, there was no documentation of continued communication with the resident and family about these issues, nor was there follow-up on the family's compliance with the storage guidelines. Interviews with facility staff, including a CNA, LVN, MDS Coordinator, and Admissions Director, confirmed awareness of the issue but revealed a lack of consistent communication and enforcement of the facility's P&P.
Improper Trash Disposal
Penalty
Summary
The facility failed to properly dispose of trash, as observed during a survey. One of three dumpsters located outside the facility was found overflowing with boxes, which prevented the lid from fully closing. This observation was made on 6/4/24 at 0755 hours. The issue was confirmed during a concurrent observation and interview with the Director of Maintenance at 0803 hours, who verified that the dumpster was indeed overflowing and the lid was not fully closed. This situation was in violation of the FDA Food Code 2013, 5-501.113, which requires receptacles and waste handling units for refuse to be kept covered with tight-fitting lids, thus potentially attracting pests and/or rodents.
Confidentiality Breach and Inaccurate Record-Keeping
Penalty
Summary
The facility failed to maintain accurate and confidential resident records, as evidenced by two specific incidents. Firstly, a binder labeled 'CDPH Annual Survey Binder' was observed on a table in the lobby for public review, containing confidential resident rosters with names and identifiers from various dates in 2021. During an interview and document review, the Administrator confirmed that these confidential rosters were mistakenly included in the binder, making protected information accessible to the public. Secondly, the facility did not accurately document Resident 29's monthly weight. A review of the resident's medical records showed inconsistent weight entries over the past six months, with a significant discrepancy in the June weight, which was recorded in kilograms instead of pounds. The Director of Nursing (DON) acknowledged the error during an interview and confirmed that the incorrect entry was due to a failure to convert the weight from kilograms to pounds, resulting in inaccurate medical records for the resident.
Inappropriate Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection control practices, compromising the safety and sanitation of the environment and increasing the risk of infection spread. On June 5, 2024, at 0410 hours, multiple briefs and blue chucks were observed stacked on top of an isolation cart in front of room A. Later, at 0515 hours, a CNA was seen distributing these items to rooms A, B, and another resident's room. During an interview at 0520 hours, the CNA admitted to placing the briefs and chucks on the isolation cart for distribution purposes, acknowledging that this practice could lead to contamination and infection spread. The CNA verified the findings, confirming the inappropriate handling of these items.
Deficiencies in Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine and glucometer. The ice machine was not cleaned and sanitized according to the manufacturer's specifications and the facility's policies and procedures. An incorrect ratio of nickel-safe cleaner was used, hot water was used instead of a sanitizing solution, and an unidentified spray bottle was used to sanitize the panels. These actions could potentially lead to the equipment not functioning as intended, posing a risk of food-borne illnesses for residents. During an inspection, yellowish slime was observed on a paper towel after wiping the inside of the ice machine, indicating improper cleaning. The Director of Maintenance admitted to using a capful of nickel-safe cleaner diluted with a little water, which did not align with the manufacturer's instructions. Additionally, the Director used hot water for sanitizing instead of the correct sanitizing solution, and the spray bottle used for sanitizing the panels was unlabeled and of unknown brand. The facility also failed to ensure the glucometer's serial number matched the one listed on the Quality Control Record. This discrepancy was discovered during an inspection of Medication Cart A, where the glucometer's serial number did not match the one documented in the quality control log. The LVN and DON confirmed that the serial numbers should match, indicating a lapse in proper documentation and equipment management.
Deficiency in Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not record measurements during bed inspections to identify areas of possible entrapment for three residents using side rails. The facility's policy requires that bed frames, rails, and mattresses leave no gaps wide enough to entrap a resident's head or body, and that maintenance staff routinely inspect beds to identify risks, including entrapment. For Resident 50, observations showed the resident lying in bed with both upper side rails elevated. The medical record indicated that the resident lacked the capacity to make decisions, and the bed rail assessment noted the use of bilateral side rails for mobility and safety. However, the maintenance director could not provide documentation of bed inspection or entrapment risk assessment for the resident's bed. Similarly, Resident 423 was observed with elevated side rails, and although a physician's order was in place for side rails, the maintenance director again failed to provide documentation of an entrapment assessment. Resident 18 was observed with elevated bed rails, and the medical record indicated fluctuating capacity to understand and make decisions. The plan of care included the use of side rails for ADL changes, mobility, and positioning. However, the maintenance director acknowledged not performing any entrapment assessment. Measurements taken by the environmental services staff revealed a gap that could potentially entrap a resident's arm or hand, confirming the deficiency in the facility's bed inspection and entrapment assessment process.
Failure to Properly Label Tube Feeding for a Resident
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for a resident, identified as Resident 45, who was reviewed for GT care. The deficiency was observed when the label on Resident 45's tube feeding bottle did not include the start time of the feeding and the initials of the nurse who hung the tube feeding. This omission was noted during observations conducted on two separate days. The facility's policy and procedure for enteral feedings, dated 9/7/23, required that the bag and tubing be labeled with the date and time hung, with a hang time of no more than 24 hours. Interviews with facility staff, including the Infection Preventionist (IP), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that the labeling process was not followed as per the facility's policy. The staff acknowledged that the label should have included the resident's name, date, start time, room number, and the nurse's initials. Resident 45, who lacked the capacity to understand and make decisions, had a physician's order for Jevity 1.2 feeding formula to be administered via pump. The failure to properly label the tube feeding had the potential to lead to complications related to tube feedings and/or risk for infections, as noted in the report.
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Nursing homes near Costa Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newport Nursing And Rehabilitation Center | 0.8 mi | — | 11 | 0 |
| Pelican Ridge Post Acute | 0.9 mi | — | 19 | 0 |
| Crystal Cove Care Center | 1 mi | — | 6 | 0 |
| Victoria Healthcare And Rehabilitation Center | 1.4 mi | — | 0 | 0 |
| Newport Subacute Healthcare Center | 2.2 mi | — | 7 | 0 |
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