Mesa Glen Care Center: Call Light Left on Floor - CA
The resident in that room, identified in inspection records only as Resident 20, had epilepsy and osteoporosis. Epilepsy causes recurring, unprovoked seizures. Osteoporosis means bones that break easily. A federal assessment from January 2025 recorded that this resident needed substantial to maximal assistance just to dress above the waist, meaning staff had to do more than half the physical work to help them get a shirt on.
Inspectors walked into the room at 11:23 in the morning on March 4, 2025, and saw the resident sitting up in bed. The call light wire was behind a pillow. The call light itself was touching the floor.
Four minutes later, a licensed vocational nurse entered the room with the inspector still present. The call light was still on the floor. The nurse said it should not be there. She said the resident needed it close by to call for assistance.
That was the finding. One resident, one room, one morning.
The facility's own written policy, last revised in September 2022, states that the call light should be accessible to the resident when in bed. The purpose of that policy, as the facility wrote it, was to ensure timely responses to residents' requests and needs.
The Director of Nursing, interviewed three days later on March 7, said the call light should be within reach in case the resident needs to call for help. She said that if the resident cannot reach it, they may not get the help they need, and that puts them at risk for injury.
That is the facility's own director of nursing, describing the risk in plain terms.
What the inspection record does not say is how long the call light had been on the floor before inspectors arrived. It does not say whether Resident 20 had tried to reach it. It does not say whether anyone had checked on this resident that morning, or how long the resident had been sitting up in bed alone before an inspector happened to walk in.
Resident 20's medical history noted a fluctuating capacity to understand and make decisions, according to a history and physical from March 2024. The more recent federal assessment from January 2025 recorded intact cognition. What either document cannot capture is what it is like to sit in a bed, unable to dress yourself, with epilepsy, with bones that fracture under ordinary stress, and have the one tool that connects you to another human being lying on the floor where you cannot reach it.
Federal inspectors rated this deficiency at the minimal harm level, the lowest tier of the rating scale. The potential, they wrote, was for delayed provision of care and negative impact on the resident's psychosocial well-being.
Psychosocial well-being is the clinical phrase. The plain version is this: a person who cannot move well, who has a condition that can drop them without warning, was left without a way to ask for help.
Mesa Glen Care Center is located at 638 East Colorado Avenue in Glendora. The inspection was completed March 7, 2025.
The nurse who saw the call light on the floor said it should not have been there. The director of nursing said the same thing three days later. The facility's own policy said the same thing, in writing, since at least 2022.
The call light was on the floor anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-03-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 10, 2026 · Our methodology
Mesa Glen Care Center in GLENDORA, CA was cited for violations during a health inspection on March 7, 2025.
The resident in that room, identified in inspection records only as Resident 20, had epilepsy and osteoporosis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.