GLENDORA, CA - Federal inspectors found serious safety violations at Mesa Glen Care Center after staff failed to properly supervise a cognitively impaired resident who had verbalized threats against another resident.
Supervision Failure Leads to Resident-on-Resident Incident
The January 7, 2025 inspection revealed that facility staff failed to implement proper safety protocols when a resident with schizoaffective disorder and bipolar disorder expressed intentions to harm another resident. The incident occurred on December 31, 2024, when the cognitively impaired resident entered another resident's room without permission, engaged in a verbal altercation, and attempted to throw objects at the victim.
According to inspection records, Resident 1 had been diagnosed with schizoaffective disorder, generalized anxiety disorder, and bipolar disorder. A comprehensive assessment from October 2024 documented that this resident had moderately impaired cognitive abilities, and a November medical examination confirmed the resident lacked capacity to understand and make decisions.
The incident escalated to the point where screaming could be heard from the victim's room, prompting staff to remove the aggressive resident. However, federal inspectors determined this intervention came too late, as proper supervision should have prevented the incident entirely.
Required Safety Protocols Ignored
Federal regulations mandate that nursing facilities maintain environments free from accident hazards and provide adequate supervision to prevent incidents between residents. When residents express threatening intentions, especially those with documented cognitive impairments, facilities must implement immediate protective measures.
The victim, Resident 5, had intact cognitive abilities and suffered chronic obstructive pulmonary disease along with anxiety. This resident was particularly vulnerable to the stress and fear that such an unprovoked incident would cause.
Proper supervision protocols should have included continuous monitoring of the threatening resident, restricting access to other residents' rooms, and potentially implementing one-on-one supervision until the situation was properly assessed and managed.
Documentation Failures Compound Safety Concerns
Inspectors also discovered that staff failed to complete required incident documentation following the altercation. The facility's Registered Nurse confirmed that no SBAR (Situation, Background, Assessment, Recommendation) form was completed for the December 31 incident, despite this being a mandatory requirement.
SBAR forms serve critical functions in nursing home operations, including monitoring resident condition changes and ensuring medical providers are notified of significant incidents. The Director of Nursing explained that failure to complete these forms means "there would be no documentation of Medical Doctor notification and staff could miss an MD order or fail to do an assessment."
The facility's own policies, revised in November 2015, clearly state that nursing supervisors must notify physicians when accidents or incidents occur involving residents, and relevant information must be gathered using the SBAR Communication Form before making such notifications.
Cognitive Impairment Increases Risk Factors
Residents with schizoaffective disorder experience combinations of schizophrenia symptoms and mood disorder episodes, making their behavior unpredictable. When coupled with bipolar disorder, these conditions can create significant safety risks for both the affected resident and others in the facility.
The presence of moderately impaired cognitive abilities further compromised this resident's ability to control impulses or understand consequences of actions. Facilities caring for such residents must maintain heightened awareness and implement appropriate behavioral management strategies.
Regulatory Violations and Implications
Federal inspectors cited the facility for violations under tag F689, which requires nursing homes to maintain accident-free environments and provide adequate supervision. The facility also received citations under F684 for failing to properly document and report the incident.
These violations were classified as causing minimal harm with potential for actual harm, affecting few residents. However, the incident highlights systemic failures in both preventive care protocols and incident response procedures.
The inspection findings demonstrate that Mesa Glen Care Center's safety procedures broke down at multiple levels, from initial threat assessment through incident documentation. Such failures can escalate quickly in environments where vulnerable residents depend on professional care and protection.
Federal regulations exist specifically to prevent resident-on-resident incidents, particularly when cognitive impairments or mental health conditions are involved. The facility's failure to implement these protections placed both residents at unnecessary risk and violated fundamental care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-01-07 including all violations, facility responses, and corrective action plans.
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