Mesa Glen Care Center: Dialysis Monitoring Failure - CA
The resident, identified in inspection records only as Resident 62, has end-stage renal disease, the point at which kidneys can no longer function on their own, and depends on dialysis three times a week, every Tuesday, Thursday, and Saturday. Dialysis runs the blood through a machine to strip out waste and excess fluid that the kidneys can no longer remove. The catheter threaded into a large vein to make that possible carries its own risks, including bleeding and infection, that nurses are supposed to monitor after every session.
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See the Derila PillowThe post-dialysis assessment form from March 1 had blank spaces throughout the section where a nurse should have recorded observations. It wasn't a matter of a missing signature or an incomplete note. The section was empty.
Licensed Vocational Nurse 2, the staff member who reviewed the form with inspectors on March 5, did not dispute what the record showed. The nurse acknowledged the pre and post assessments need to be completed whenever a resident leaves the facility for dialysis, confirmed the form was left blank, and said that without it, staff had no way to monitor for unstable vital signs or bleeding at the catheter site.
The Director of Nursing, interviewed two days later on March 7, said the same thing from the other direction. Without the form, the status of the resident would be unknown. There would be no documentation of baseline vital signs, no record of any monitoring of the access site. The director did not explain why the form had been left blank or describe any corrective action already taken.
Resident 62 had been assessed as cognitively intact, capable of understanding and making decisions. That detail matters here not because it changes what happened to the resident, but because it forecloses any suggestion that communication difficulties contributed to the lapse. A nurse simply did not complete the form.
The facility's own hemodialysis policy, revised as recently as February 2023, requires nurses to document post-dialysis observations every shift. The March 1 entry represents a straightforward failure to follow a procedure the facility wrote and updated itself.
Federal inspectors rated the violation as having the potential for actual harm, a level that reflects the gap between what could have happened and what, as far as the record shows, did. Dialysis patients are vulnerable to complications in the hours after treatment. Blood pressure can drop. The catheter site can bleed. Without a documented baseline from the moment the resident returned to the facility, any nurse coming on shift would have had nothing to compare against if the resident's condition changed.
The inspection was completed March 7, 2025. Mesa Glen Care Center is located at 638 East Colorado Avenue in Glendora.
What the record does not say is whether anyone checked on Resident 62 that day through some other means, whether a nurse noticed anything concerning and simply failed to write it down, or whether the resident came back from dialysis and was left largely to themselves. The form was blank. That is what the inspectors found, and that is what the Director of Nursing confirmed: when the form is not filled out, the status of the resident is unknown.
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 13, 2026 · Our methodology
Mesa Glen Care Center in GLENDORA, CA was cited for violations during a health inspection on March 7, 2025.
Dialysis runs the blood through a machine to strip out waste and excess fluid that the kidneys can no longer remove.
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.