Mesa Glen Care Center was administering Olanzapine, an antipsychotic medication, to Resident 5 twice daily for "schizoaffective disorder manifested by verbal aggression toward others," according to physician orders reviewed during the March 7, 2025 federal inspection. But when inspectors examined the resident's informed consent forms, they found no signature from the resident.
"Resident 5 stated facility staff tried to give her a pill this morning, and Resident 5 refused to take the pill," inspectors wrote. "Resident 5 stated Resident 5 has not signed nothing about medication. Resident 5 stated Resident 5 does not have schizophrenia and does not need the medication."
Registered Nurse 4 confirmed during interviews that the informed consent for both Olanzapine and Lorazepam medications was not signed by Resident 5. "If the Informed Consent was not signed, there was no consent," RN 4 told inspectors.
The nurse explained the significance: "It is important to obtain an Informed Consent because medication is considered a chemical restraint." Licensed Vocational Nurse 4 added that staff needed permission to administer antipsychotic medication because residents "may have side effects from the medication" and "chemical restraint cannot be done against their will."
The facility's own policy, dated March 2024, required written informed consent signed by the resident or representative before prescribing psychotherapeutic drugs. The policy mandated that staff verify the resident's health record contained proper consent with required signatures before initiating treatment.
Multiple Safety Failures Documented
The medication consent violation was one of eight deficiencies found during the inspection, which revealed a pattern of safety lapses affecting multiple residents.
In one room, inspectors found a resident's call light "touching the floor" with the wire behind a pillow, making it impossible for the resident to summon help. Licensed Vocational Nurse 2 stated "the resident's call light should not be under the pillow or touching the ground because Resident 20 needed it close by to call for assistance."
Director of Nursing told inspectors that if residents cannot reach their call light, "they may not get the help they need, putting them at risk for injury."
Maintenance problems created additional hazards. Resident 63's toilet seat was loose and missing a screw, leaving it detached from the toilet rim. The resident's responsible party had reported the broken toilet seat to staff after returning from a family outing on March 2, but it remained unfixed when inspectors arrived days later.
The Director of Nursing acknowledged the danger: "There's a risk the resident could fall when the toilet seat moved off the toilet."
In another room, a patio sliding door near a resident's bed remained open approximately one inch, allowing cold air and potentially insects inside. The Maintenance Supervisor found dirt in the door track and was unable to fully close it, stating "the patio sliding door should not remain open and stated it was going to rain that day."
Abuse Reporting Failure
The facility also failed to properly report an alleged assault between residents. On January 22, 2025, Resident 51 struck Resident 10 in the face during a medication pass. Resident 10 later told inspectors: "Resident 10 felt traumatized from the incident."
While the facility attempted to report the incident to the California Department of Public Health within the required two-hour timeframe, the Social Services Director admitted they "faxed it to the wrong number."
The Director of Nursing confirmed the reporting failure placed both residents at risk because "CDPH would not be able to investigate the abuse allegation in a timely manner."
Critical Care Plan Gaps
Inspectors found the facility failed to develop comprehensive care plans for four residents, including missing plans for antipsychotic medication management, elopement attempts, and PTSD treatment.
Resident 196 had attempted to leave the facility on March 4, exiting through double doors and triggering alarms while staff followed him to the parking lot. The same day, he was involved in a physical altercation with his roommate. Licensed Vocational Nurse 3 told inspectors no care plan was created for either incident.
"The risk of not creating a CP for elopement was putting the resident at risk for future elopements because interventions would not have been implemented to prevent future attempts," LVN 3 explained.
Another resident with a PTSD diagnosis had no care plan addressing the condition. Licensed Vocational Nurse 5 said this was problematic because "PTSD could impact a person's emotional and psychological well-being and knowing about the diagnosis helped staff tailor their approach to meet the resident's specific needs."
Pressure Ulcer Prevention Problems
The facility failed to properly operate specialized mattresses designed to prevent pressure sores. Inspectors found low air loss mattresses set to static pressure instead of alternating pressure for multiple residents at risk of skin breakdown.
Licensed Vocational Nurse 2 explained that when mattresses remain on static pressure, "the mattress remained fully inflated, stopping air from fluctuating inside the mattress, which could prevent wound healing."
The Director of Nursing confirmed that mattresses left on static pressure "could be hard and could cause injury to the resident's skin." The static setting was only meant to be used during bedside care, not continuously.
One resident with an active physician order for heel boots to prevent pressure ulcers was observed without the protective devices. Licensed Vocational Nurse 6 explained that not following the physician's order "could lead to unnecessary complications" for a resident with limited mobility at risk for skin breakdown.
Advance Directive Documentation Failures
Seven residents had incomplete or inaccurate advance directive paperwork, potentially affecting end-of-life care decisions. The Social Services Director acknowledged that incomplete forms "would place residents at risk of receiving the incorrect emergency treatment."
In one case, the wrong family member had signed a resident's advance directive forms. The Social Services Director discovered that the person listed as the responsible party in the admission record was "just a visitor and was not authorized to sign" the resident's documents.
The Director of Nursing emphasized the importance of accurate advance directive documentation: "The form should be filled out immediately upon admission" because incomplete forms "places the resident at risk of providing the wrong emergency treatment and not honoring the resident's wishes."
The facility also failed to submit required resident assessment data within federal deadlines, with one resident's assessment transmitted late after their death, and missed required IV line maintenance for a resident with specialized catheters.
These violations occurred at a 74-bed facility that provides skilled nursing and rehabilitation services in the San Gabriel Valley.
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.