GLENDORA, CALIFORNIA - A state inspection at Mesa Glen Care Center uncovered critical failures in supervision and monitoring that resulted in multiple residents experiencing serious injuries, including head lacerations requiring emergency treatment, facial fractures from physical altercations, and preventable falls among vulnerable residents with cognitive impairments.
Physician-Ordered Monitoring Ignored for Vulnerable Resident with Huntington's Disease
Mesa Glen Care Center failed to implement crucial hourly monitoring for a resident with Huntington's Disease and dementia who exhibited dangerous self-injurious behaviors, leading to two separate incidents requiring emergency hospital treatment within a 48-hour period.
Resident 37, diagnosed with Huntington's Disease and dementia, had documented behaviors of banging their head against walls and punching walls. Despite a physician's order dated February 2, 2025, requiring hourly monitoring for aggressive behavior every shift, nursing staff failed to implement this critical safety measure.
On March 2, 2025, the resident was observed walking in the hallway when they suddenly threw a remote control to the floor and struck their head against a door with such force that it caused a 2.5-centimeter laceration on top of their head. The wound measured 0.3 cm in width and depth, causing bleeding that required emergency transport to the hospital where medical staff repaired the laceration using surgical skin adhesive.
Just two days later, on March 4, the situation escalated dramatically when Resident 37 became involved in a physical altercation with their roommate. The resident sustained a bloody mouth, bloody nose, and a small bump on the forehead after being punched in the face. Emergency department imaging revealed a mildly displaced nasal septal fracture and a frontal scalp hematoma. The resident reported experiencing 10 out of 10 pain following this incident.
When investigators reviewed records and interviewed staff, they discovered that no hourly behavioral monitoring sheets had been created for the resident on March 2 or March 3. The monitoring sheet for March 4 was only created after the altercation had already occurred. Multiple staff members, including certified nursing assistants and licensed vocational nurses, admitted they were unaware the resident required hourly monitoring despite the active physician's order.
The facility's Director of Nursing acknowledged during the investigation that "The incidents on 3/2/2025 and 3/4/2025 could have been prevented if hourly monitoring was done."
Cognitively Impaired Resident Falls While Reaching for Meal Tray
In a separate incident highlighting inadequate supervision protocols, a resident with severe cognitive impairment and documented fall risk experienced a preventable fall when staff inappropriately delivered a meal tray without being present to provide required feeding assistance.
Resident 294, who had been admitted with toxic encephalopathy and severe cognitive impairment, was completely dependent on staff for eating and had been assessed as a moderate fall risk. The resident also had functional impairment in both upper extremities and required substantial assistance with all activities of daily living.
On March 5, 2025, maintenance staff discovered the resident sitting on the floor with their back against the bed, reaching for a lunch tray that had been placed on the bedside table between the window and bed. The resident had attempted to reach the tray independently despite being unable to feed themselves safely.
Staff interviews revealed a fundamental breakdown in safety protocols. The licensed vocational nurse who responded stated the resident "was dependent with eating, had been identified as a fall risk, was cognitively impaired, and had episodes of confusion." The nurse emphasized that "staff should not have delivered Resident 294's lunch tray until staff were ready to assist with feeding the resident, which could have prevented the fall."
Cognitive impairment significantly affects a person's ability to recognize physical limitations and environmental hazards. Residents with toxic encephalopathy often experience altered consciousness, memory loss, and impaired judgment, making them particularly vulnerable to falls when left unsupervised with potential hazards like meal trays placed within reach but beyond their safe grasp.
The facility's Director of Nursing confirmed that meal trays should never be delivered to confused and dependent residents unless staff are immediately available to provide feeding assistance, acknowledging this practice ensures residents are not left in vulnerable situations where they might attempt unsafe actions independently.
Critical Failures in Pain Management and Medical Communication
The inspection also revealed systemic failures in pain management protocols affecting multiple residents. In one case, recommendations from a pain specialist were never communicated to the attending physician, leaving a resident on unnecessary medications while appropriate non-pharmacological interventions went unimplemented.
A pain specialist had recommended on two separate occasions that staff attempt non-pharmacological interventions before administering pain medications for a resident receiving Gabapentin three times daily. Both recommendations explicitly stated that all suggestions should be communicated to the referring physician for approval. However, these critical recommendations were never forwarded, and the resident continued receiving medications without any attempt at alternative pain management strategies.
Another resident repeatedly reported pain levels of 8 or 9 out of 10 over multiple days, with current pain medications proving ineffective. Despite the resident's complaints and consistently high pain scores documented in medication administration records, nursing staff failed to notify the physician that the current pain management regimen was inadequate. One nurse admitted being "swamped" and not having time to contact the physician about the uncontrolled pain.
Additional Issues Identified
The inspection uncovered numerous other violations including a resident with end-stage renal disease whose post-dialysis assessments were not completed, potentially missing critical complications following treatment. Another resident receiving oxygen therapy had no physician's order for the treatment and lacked required "No Smoking/Oxygen in Use" signage on their door, creating significant fire hazards in the facility.
The facility also failed to notify physicians when a resident experienced a 17-pound weight loss within one month, failed to provide proper catheter care according to physician orders on multiple dates, and did not address Post-Traumatic Stress Disorder care needs for an affected resident.
These widespread failures in basic nursing protocols demonstrate systemic breakdowns in communication, supervision, and implementation of physician orders throughout Mesa Glen Care Center. The violations affected residents with complex medical conditions including Huntington's Disease, dementia, end-stage renal disease, and toxic encephalopathy - all conditions requiring heightened vigilance and consistent implementation of care protocols to prevent serious complications and injuries.
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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