Latest reports, citations, and penalties from CMS data
Social services staff were actively working on community placement and had scheduled housing paperwork review for November 11, 2024....
State inspectors found that pain management protocols were inconsistent with professional standards and residents' care plans....
The inspection findings revealed that administrative oversight failures created conditions that compromised fundamental aspects of resident care....
This violation received an F-level citation, indicating widespread systemic issues with potential for more than minimal harm to residents....
Yellow dried material consistent with urine was visible on the broken toilet seat, which hung sideways from the fixture....
The situation became more complex due to the resident's documented allergy to aspirin, a common blood thinner....
This practice affected multiple vulnerable residents, including those with severe cognitive impairment, mobility limitations, and histories of falls....
The resident, who had a below-knee amputation and used a wheelchair, left the facility during a day when temperatures reached 95 degrees Fahrenheit....
The primary violation centered on the facility's deep fryer, which had accumulated dangerous levels of grease buildup in its internal compartment....
Similarly, a Mantoux vial used for tuberculosis testing had exceeded the manufacturer's 30-day use window after opening but remained in storage....
Federal inspection of Mesa Glen Care Center in Glendora, CA on April 15, 2025 revealed violations requiring immediate correction....
The 36-bed facility has repeatedly faced citations for insufficient nursing staff, indicating a systemic failure in their quality improvement processes....
Some staff reported that previous administrators would purchase food to pacify the aggressive resident rather than addressing the underlying behavioral issues....
This delay in medical notification prevented timely interventions that could prevent minor issues from escalating into serious medical emergencies....
The resident, identified as R8, was discovered on December 22, 2024, in a compromised position after attempting to get out of bed....
The violations centered on two critical incidents: an allegation of staff-to-resident physical abuse and a resident elopement from the facility....
This disruption affected at least four residents who required essential blood work to monitor medication levels and health conditions....
During the inspection, surveyors observed Resident 4 lying in bed with both upper side rails raised without proper authorization or safety protocols....
## Critical Gaps in Medical Device Management State inspectors identified concerning lapses in care for residents requiring specialized medical equipment....
During the inspection, **surveyors observed the resident raising her buttocks and waist from her bed with no alarm sounding**....