Mesa Glen Care Center: Fall Investigation Failures - CA
Two residents experienced multiple falls between July and August 2025, but administrators never convened the interdisciplinary team meetings designed to prevent future incidents.
Resident 9 fell twice during this period. The first was an unwitnessed fall on July 11, with staff notifying the physician at 10:15 AM that same day. The second occurred on August 25 when staff witnessed the fall and called the physician at 7 AM.
Nobody held the required post-fall team meeting for either incident.
Resident 6 also fell twice in July 2025. Again, no interdisciplinary team meeting followed either fall.
When inspectors interviewed Registered Nurse 2 on September 3, the nurse confirmed the facility had conducted no team meetings for any of these falls. The nurse acknowledged that facility protocol required conducting an interdisciplinary team meeting the day after any resident fall.
The Director of Nursing made the same admission during a September 4 interview. She told inspectors the facility should hold post-fall team meetings for all residents who experience falls.
Mesa Glen's own written policies spelled out these requirements clearly. The facility's "Safety and Supervision of Residents" policy, revised in July 2017, stated that "the interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risks for individual residents."
The "Falls Clinical Protocol" policy, updated in March 2018, was even more specific about timing. It required that "for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall."
The policy acknowledged that "often multiple factors contribute to a falling problem," making the team analysis crucial for prevention.
These interdisciplinary meetings serve as a facility's primary tool for preventing repeat falls. Team members typically include nurses, therapists, social workers, and other staff who can identify environmental hazards, medication interactions, or physical changes that might increase fall risk.
Both residents who fell multiple times required assistance with daily activities. Resident 9 needed help with eating, oral hygiene, toileting, bathing, and upper body dressing. Such residents often face higher fall risks due to mobility limitations or cognitive impairment.
The inspection occurred September 5, 2025, following a complaint. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "some" residents.
The failure to conduct post-fall reviews violated federal nursing home regulations requiring facilities to ensure resident safety and prevent accidents. These meetings are considered essential for identifying patterns and implementing preventive measures.
Mesa Glen Care Center operates at 638 E Colorado Avenue in Glendora. The facility's systematic failure to follow its own fall prevention protocols left vulnerable residents without the safety analysis designed to protect them from future injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-09-05 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.
Resident 9 fell twice during this period.
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.