Mesa Glen Care Center: Consent Falsified for Psych Meds - CA
The four drugs were Alprazolam, a benzodiazepine used to treat anxiety; Citalopram Hydrobromide, an antidepressant; Mirtazapine, another antidepressant; and Seroquel, an antipsychotic. Each comes with its own risks. Each requires a patient or their authorized representative to be told what the drug does, why it is being prescribed, and what the alternatives are, before agreeing to take it.
The consent forms said otherwise. All four listed the nurse practitioner, identified in inspection records as NP 1, as the person who obtained consent from the resident's representative on the day of readmission. When inspectors interviewed NP 1, she told them directly: she did not obtain informed consent from the resident's representative for any of the four psychotropic medications on October 15.
Inspectors reviewed the forms during their November 2025 complaint investigation. The discrepancy was not subtle. The forms said one thing. The clinician whose name was on them said the opposite.
The Director of Nursing, interviewed on November 20 at 12:23 p.m., confirmed that the prescribing healthcare provider is responsible for obtaining informed consent when a resident is readmitted with existing orders for psychotropic medications. She confirmed that consent must be obtained at readmission. She did not dispute that it had not happened here.
The facility's own written policy, though undated, is unambiguous. If a resident arrives with existing orders for psychoactive medications and no documentation exists proving a discharging physician already obtained consent, the admitting physician is responsible for getting it before the medications are given. No such documentation was present for this resident. No admitting physician obtained consent. Four forms were generated anyway, bearing the name of a clinician who says she had no part in them.
What the forms recorded did not happen. What was supposed to happen instead also did not happen.
The resident in this case had a representative, identified in inspection records as RR 1, who should have been the person sitting across from a clinician, hearing what Seroquel does to an elderly patient's brain, what Alprazolam does to balance and cognition, why Mirtazapine was being prescribed and what the risks were. That conversation, if it happened at all, was not documented by anyone who actually had it.
CMS rated the violation at the level of minimal harm or potential for actual harm, meaning inspectors did not find evidence that the resident suffered a direct physical consequence from the paperwork failure. But the harm that informed consent is designed to prevent is not always visible after the fact. It lives in the decision that was never made, the question that was never asked, the family member who never got to say no.
Mesa Glen Care Center is a licensed skilled nursing facility in Glendora, in the San Gabriel Valley east of Los Angeles. The complaint inspection that surfaced this finding was conducted on November 21, 2025.
The resident's representative never got that conversation. The forms say they did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Glen Care Center from 2025-11-21 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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 27, 2026 · Our methodology
Mesa Glen Care Center in GLENDORA, CA was cited for violations during a health inspection on November 21, 2025.
The consent forms said otherwise.
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.