Mesa Glen Care Center: Failed to Report Weight Loss - CA
Federal inspectors found Mesa Glen Care Center violated notification requirements when Resident 7 dropped from 144 pounds to 127 pounds between June 9 and July 7, 2025. The 11.8% weight loss qualified as significant under the facility's own policies, but no Change in Condition Evaluation was created to alert the physician.
Resident 7 had been admitted with multiple rib fractures, hypertensive heart disease, a urinary tract infection, and protein-calorie malnutrition. The resident required substantial to maximal assistance with toileting, bathing, and lower body dressing, and was moderately impaired in cognitive skills for daily decisions.
The weight loss continued after July. By August 22, Resident 7 weighed just 118 pounds — 26 pounds below the June weight. The facility's Weight Summary Report confirmed more than 10% weight loss in less than 180 days by July 1.
During the September 2 inspection, the Director of Nursing admitted there was no Change in Condition Evaluation for the significant weight loss in June, July, or August 2025. "The facility should create a CICE for the resident's significant weight loss," the director told inspectors.
Mesa Glen's own policies required notification. The facility's Change in Condition policy, revised February 2021, stated nurses "will notify the resident's attending physician or on call physician when there has been a significant change in the resident's physical/emotional/mental condition."
The nutrition protocol was even more specific. Staff were required to "report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake," according to the September 2017 policy.
The facility had clear thresholds for what constituted significant weight loss. A 5% loss in one month was significant, with anything greater than 5% considered severe. Resident 7's 11.8% monthly loss far exceeded both benchmarks.
The weighing policy required staff to "report significant weight loss/weight gain to the nurse supervisor." But no supervisor created the required evaluation to notify the doctor, despite the resident's documented malnutrition diagnosis and continuing decline.
Progress notes from July 9 documented the "significant unintentional weight loss of 17 LBs (11.8%) over the past 30 days." A History and Physical completed July 16 confirmed the resident had capacity to make medical decisions.
The failure meant Resident 7's doctor remained unaware of the deteriorating condition for months. Without physician notification, the resident could not receive timely treatment to address the weight loss, potentially affecting health and wellbeing.
Inspectors found the violation had potential for actual harm. The resident's existing malnutrition diagnosis made the continued weight loss particularly concerning, but the facility's communication breakdown prevented medical intervention.
The case illustrates how administrative failures can compound medical conditions. Resident 7 entered the facility already malnourished and continued losing weight at an alarming rate. The facility documented the decline but failed to follow its own procedures to ensure the doctor knew about it.
Mesa Glen's policies recognized weight loss as a serious medical concern requiring immediate physician notification. But those protections meant nothing when staff didn't implement them, leaving a vulnerable resident without proper medical oversight during a critical health decline.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mesa Glen Care Center in GLENDORA, CA was cited for violations during a health inspection on September 5, 2025.
The 11.8% weight loss qualified as significant under the facility's own policies, but no Change in Condition Evaluation was created to alert the physician.
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.