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Complaint Investigation

Mesa Glen Care Center

January 7, 2025 · Glendora, CA · 638 E Colorado Avenue
Citations 2
CMS Rating 1/5
Beds 96
Provider ID 555854
Healthcare Facility
Mesa Glen Care Center
Glendora, CA  ·  View full profile →
Inspection Summary

Mesa Glen Care Center in GLENDORA, CA — inspection on January 7, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF684
Minimal harm or Few affected

During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood), generalized anxiety disorder, and bipolar disorder (mental illness that causes extreme mood swings).

During a review of Resident 1 ' s Minimum Data Set (MDS,a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/31/2024, the MDS indicated Resident 1 ' s cognitive abilities (ability to think, learn, and process information) were moderately impaired.

During a review of Resident 1 ' s History and Physical (H&P, formal document of a medical provider ' s examination of a patient) dated 11/23/2024 indicated Resident 1 did not have the capacity to understand and make decisions.

During a review of Resident 1 ' s untimed Situation Background Assessment Recommendation Communication Form (SBAR) dated 12/31/2024, untimed, the SBAR indicated Resident 1 verbalized Resident 1 wanted to hurt someone and indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) for psychiatric evaluation on 12/31/2024 at 10 PM.

b.

During a review of Resident 5 ' s AR, the AR indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, chronic lung disease that makes it difficult to breathe) and anxiety.

During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognitive abilities were intact.

During a review of Resident 5 ' s untimed SBAR dated 12/31/2024, untimed, the SBAR indicated on 12/31/2024 at 5:31 PM there was screaming from Resident 5 ' s room and staff moved Resident 1 in the wheelchair out of Resident 5 ' s room.

The SBAR indicated Resident 1 grabbed shoes when moved out of Resident 5 ' s room.

555854

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555854 B.

Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Glen Care Center 638 E Colorado Avenue Glendora, CA 91740

During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (mental disorder that is characterized by abnormal thought processes and an unstable mood), generalized anxiety disorder, and bipolar disorder (mental illness that causes extreme mood swings).

During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/31/2024, the MDS indicated Resident 1 ' s cognitive abilities (ability to think, learn, and process information) were moderately impaired.

During a review of Resident 1 ' s History and Physical (H&P, formal document of a medical provider ' s examination of a patient) dated 11/23/2024 indicated Resident 1 did not have the capacity to understand and make decisions.

b.

During a review of Resident 5 ' s AR, the AR indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, chronic lung disease that makes it difficult to breathe) and anxiety.

During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognitive abilities were intact.

During a review of Resident 5 ' s SBAR dated 12/31/2024, untimed, the SBAR indicated on 12/31/2024 at 5:31 PM there was screaming from Resident 5 ' s room and staff moved Resident 1 in the wheelchair out of Resident 5 ' s room.

The SBAR indicated Resident 1 grabbed shoes when moved out of Resident 5 ' s room.

During a concurrent interview and record review on 1/7/2025 at 1:38 PM with Registered Nurse 1 (RN 1), Resident 1 ' s SBAR ' s for 12/2024 were reviewed. RN 1 stated there was no SBAR for Resident 1 for the incident between Resident 1 and Resident 5 on 12/31/2024. RN 1 stated the purpose of filling out a SBAR was to monitor for changes and to indicate if the MD was made aware of the incident. RN 1 stated an SBAR should ' ve been completed.

555854

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555854 B.

Wing 01/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Glen Care Center 638 E Colorado Avenue Glendora, CA 91740

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDORA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mesa Glen Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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