Mesa Glen Care Center: Catheter Care Gaps Found - CA
A Foley catheter is a tube inserted into the bladder to drain urine. Residents who rely on one depend entirely on staff to keep it clean, check its position, and watch for the buildup of sediment that signals bacterial growth. When that monitoring stops, the path to a urinary tract infection, an infection that can spread from the bladder to the kidneys and into the bloodstream, becomes short.
The treatment nurse did not dispute what the blank entries meant. If it was blank, she told inspectors, the catheter care was not done. She explained that treatment nurses are responsible for checking the bags and changing them as needed to keep the catheter clean. If care was not completed as the physician ordered, she said, the resident would be at risk of developing a urinary tract infection because staff was not monitoring the catheter.
The Director of Nursing said the same thing, in almost the same words.
During an interview on March 7 at 1:40 p.m., the Director of Nursing told inspectors that nursing staff are required to monitor the catheter every shift, checking for proper placement and for sediment. If that was not done, the director said, it would put the resident at risk for developing an infection.
The facility's own catheter care policy, last revised in August 2022, states that the date and time catheter care is given must be recorded in the resident's medical record. The blank spaces on March 3 and March 4 were not a documentation error that might mask care that happened anyway. The treatment nurse made clear they were an absence of care.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The finding was one of several deficiencies documented during the March 7, 2025 inspection.
What the inspection record does not show is how long the gaps persisted before anyone noticed, or whether the resident who went without catheter monitoring on those two days developed symptoms afterward. The logs showed the blanks. The nurses confirmed what the blanks meant. The record stops there.
For a resident with a Foley catheter, two days without the monitoring their physician ordered is not an abstraction. Urinary tract infections in older adults with indwelling catheters can escalate quickly, moving from localized discomfort to systemic illness before the cause is identified. The treatment nurse who spoke to inspectors understood this. The Director of Nursing understood this. Both said so directly.
The care simply was not done.
Mesa Glen Care Center operates at 638 East Colorado Avenue in Glendora. The inspection was completed March 7, 2025.
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 11, 2026 · Our methodology
Mesa Glen Care Center in GLENDORA, CA was cited for violations during a health inspection on March 7, 2025.
A Foley catheter is a tube inserted into the bladder to drain urine.
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.