GLENDORA, CA - State health inspectors documented significant violations at Mesa Glen Care Center during a March 7, 2025 inspection, finding that nursing staff lacked critical training on mental health conditions and residents experienced extended wait times for basic care assistance, with some waiting over an hour for help with toileting and oxygen equipment.
Inadequate PTSD Training Leaves Resident Without Proper Support
The inspection revealed that none of the facility's 106 nursing staff members had received training on Post-Traumatic Stress Disorder, despite caring for a resident with this diagnosis. The resident, identified as Resident 47 in the report, had been admitted to the facility with diagnoses including sickle-cell disease, bipolar disorder, and PTSD.
During the inspection, Resident 47 described experiencing significant challenges due to staff's lack of understanding about PTSD. "It felt like no one at the facility really understood her or knew how to respond to her triggers," the resident told inspectors. She explained that when staff approached her in certain ways or came too close too quickly, her body would automatically enter a fight-or-flight response that she could not control.
The resident reported that when these reactions occurred, staff members appeared to interpret her behavior as being difficult or acting out without reason, rather than recognizing these as PTSD-related responses. She emphasized that increased awareness from staff about her condition would make a significant difference in her care.
Interviews with multiple staff members confirmed the training gap. A Certified Nursing Assistant stated they had heard of PTSD and knew it was related to traumatic events but could not provide specific details and was unaware of any residents with the diagnosis. Another CNA admitted not knowing what PTSD was at all and could not recall receiving any training on the topic.
Even a Licensed Vocational Nurse who could define PTSD and explain its effects was unaware that Resident 47 had this diagnosis. The nurse acknowledged that knowing about a resident's PTSD diagnosis was critical because it directly affected how care should be approached, allowing staff to tailor their methods to meet specific needs.
Extended Wait Times for Essential Care
The inspection documented multiple instances where residents waited excessive periods for assistance with basic needs. Three residents with varying levels of cognitive impairment and physical assistance requirements experienced delays ranging from 30 minutes to two hours for help with essential activities.
Resident 6, who was legally blind and required substantial assistance with toileting, reported regularly waiting an hour or more for staff to change incontinence pads. During one observed incident, the resident activated the call light and was told by a staff member that they would notify the assigned CNA when that person returned from lunch. However, the returning CNA failed to communicate with the covering staff member and instead went to assist other residents in a different area of the facility.
"I have to wait an hour or more for staff to change me and I have a sore on my bottom," Resident 6 told inspectors. During the inspection, observers documented the resident calling out for their nurse while staff members in the hallway did not acknowledge the calls for help.
Resident 5, who required oxygen therapy and assistance with dressing, reported waiting up to an hour at night and 30 minutes during the day for staff to help with putting on the nasal cannula for oxygen delivery. When the resident complained about the delays, staff reportedly told the resident they had been asleep, to which the resident responded that sleep occurred because of the extended waiting periods.
Systemic Communication Failures
The inspection revealed breakdowns in basic communication protocols among staff members. The facility's policy required CNAs to inform colleagues when leaving their assigned area or going on breaks, ensuring continuous coverage for resident care. However, staff members failed to consistently follow these protocols.
One CNA acknowledged forgetting to inform the covering staff member about returning from lunch and working in a different area of the facility. This lapse in communication directly contributed to Resident 6's extended wait for assistance. Other CNAs confirmed that endorsing resident care to another staff member when leaving the unit was facility policy, but the practice was not being consistently followed.
The Director of Nursing stated that all staff, including housekeeping personnel, were trained to respond to call lights, even if only to acknowledge the resident and locate appropriate care staff. The DON indicated that call lights should be answered within ten minutes at most, emphasizing the importance of timely response since staff cannot know whether residents are experiencing emergencies such as breathing difficulties.
Medical Context and Standards of Care
Post-Traumatic Stress Disorder requires specialized understanding and approaches in healthcare settings. When individuals with PTSD experience triggers, their physiological responses are involuntary and can include increased heart rate, hypervigilance, emotional dysregulation, and defensive behaviors. Without proper training, staff may misinterpret these responses as behavioral problems rather than symptoms requiring therapeutic intervention.
The extended wait times documented at Mesa Glen Care Center pose serious health risks. For residents requiring oxygen therapy, delays in receiving assistance with equipment can lead to decreased oxygen saturation, potentially causing confusion, cardiac stress, and other complications. For residents with incontinence, prolonged exposure to moisture increases the risk of pressure injuries, urinary tract infections, and skin breakdown - particularly concerning given that Resident 6 already reported having a sore.
Industry standards dictate that facilities must ensure staff competency in managing all resident diagnoses and that call light response times should typically not exceed 5-10 minutes for non-emergency situations. The facility's own policies aligned with these standards but were not being effectively implemented.
Leadership Response and Additional Issues
The Director of Staff Development acknowledged being unaware of any residents with PTSD diagnoses in the facility and had not included PTSD-specific content in staff training programs. Both the Director of Staff Development and Director of Nursing recognized the critical importance of PTSD awareness for providing appropriate care, with the DON noting that many facility residents had likely experienced trauma.
The Director of Nursing emphasized that PTSD training would benefit all staff members who had direct contact with residents, enabling them to approach care with appropriate sensitivity and compassion while creating an environment that supported healing and reduced potential triggers.
During a Resident Council Meeting, another resident confirmed the systemic nature of the delays, stating that while staff tried their best, staffing shortages contributed to wait times of 30 minutes to an hour for assistance. This resident reported attempting to help their roommate when possible due to the extended response times.
Additional Issues Identified
The inspection also documented violations of the facility's own policies regarding behavioral assessment and monitoring. The facility's procedures required behavioral health services to be provided by qualified staff with appropriate competencies, yet staff members demonstrated they lacked basic knowledge about PTSD symptoms and management. The facility's staffing policy committed to providing sufficient numbers of nursing staff with appropriate skills, but the documented delays and training gaps indicated this standard was not being met.
The inspection findings indicated these deficiencies affected multiple residents across different units and shifts, suggesting systemic rather than isolated problems. The facility's policies appropriately outlined requirements for timely call light response and proper staff communication during shift changes, but implementation and enforcement of these policies appeared to be lacking.
These violations underscore the critical importance of comprehensive staff training on mental health conditions and maintaining adequate staffing levels to meet resident needs promptly. The documented delays in basic care provision and lack of specialized training create conditions where residents' physical and psychological well-being may be compromised.
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.
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