Mesa Glen Care Center

F-F684

Findings:

a. During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] 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 REDACTED] and readmitted on [DATE REDACTED] 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 REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 555854 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 c. During a review of Resident 4 ' s AR, the AR indicated Resident 4 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included COPD. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 4 ' s MDS dated [DATE REDACTED], the MDS indicated Resident 4 ' s cognitive abilities were intact. Residents Affected - Few

During an interview on 1/7/2025 at 11:27 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 told RN 1 that Resident 1 wanted to hurt someone on 12/31/2024 at 5 PM. RN 1 stated no staff members were with Resident 1 when Resident 1 was found in Resident 2 ' s room. RN 1 stated the incident between Resident 1 and Resident 2 could have been avoided because there were no staff members watching Resident 1.

During an interview on 1/7/2025 at 1:06 PM with Social Services Assistant 1 (SSA 1), SSA 1 stated Resident 1 stated Resident 1 was afraid Resident 1 would get upset and hurt Resident 2. SSA 1 stated SSA 1 walked Resident 1 to the nursing station and informed RN 1 about the situation and stated Resident 1 wanted to be sent to the hospital because Resident 1 was Upset. SSA 1 stated Resident 1 was sitting at the nursing station before SSA 1 left the facility. SSA 1 stated Resident 1 had feelings to specifically hurt Resident 2. SSA 1 stated the incident between Resident 1 and Resident 2 could ' ve been prevented and stated the risk of not monitoring Resident 1 was that Resident 1 could hurt other residents or self.

During a concurrent interview and record review on 1/7/2025 with RN 1, Resident 1 ' s Hourly Behavioral Monitoring Sheet (HBMS) dated 12/31/2024 was reviewed. The HBMS indicated monitoring for verbal aggressiveness: screaming, yelling, curing, threatening, and grabbing stuff to have started at 7 PM on 12/31/2024. RN 1 stated hourly monitoring was started two hours after Resident 1 claimed to have feelings to hurt Resident 2. RN 1 stated if RN 1 knew Resident 1 was at the nursing station, RN 1 would ' ve placed a sitter with Resident 1. RN 1 stated hourly monitoring should ' ve started at 5 PM instead of 7 PM and stated

the risk of delayed monitoring was miscommunication between staff members and the safety of residents.

During an interview on 1/7/2025 at 2:09 PM with Resident 4, Resident 4 stated Resident 4 witnessed the incident and stated Resident 1 came into the room and said Resident 1 didn ' t like Resident 5. Resident 4 stated Resident 1 said Resident 5 was too crabby. Resident 4 stated Resident 4 saw Resident 1 put Resident 1 ' s hands inside of Resident 5 ' s boxes and throw an item in the direction of Resident 5. Resident 4 stated Resident 1 said that Resident 1 can ' t stand Resident 5 anymore. Resident 4 stated the incident scared Resident 4.

On 1/7/2025 at 2:25 PM Resident 5 refused to be interviewed.

During an interview on 1/7/2025 at 3:29 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated LVN 2 was working on 12/31/2024 when the incident occurred. LVN 2 stated LVN 2 heard screaming and yelling from Resident 5 ' s room and saw Resident 1 in Resident 5 ' s room holding a shoe. LVN 2 stated Resident 5 was telling Resident 1 to get out of Resident 5 ' s room. LVN 2 stated a staff member was not assigned to watch Resident 1 and stated LVN 2 was not aware that Resident 1 had feelings to hurt residents until after

the incident occurred. LVN 2 stated the incident could ' ve been prevented if a sitter or close monitoring was initiated when Resident 1 had reported feelings of wanting to hurt someone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 555854 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview on 1/7/2025 at 3:40 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated CNA 1 worked on 12/31/2024 when the incident occurred. CNA 1 stated CNA 1 was not aware Resident 1 had Level of Harm - Minimal harm or feelings of wanting to hurt others or Resident 5. CNA 1 stated no one mentioned Resident 1 needed to be potential for actual harm monitored prior to the incident.

Residents Affected - Few During a concurrent interview and record review on 1/7/2025 at 4:36 PM with the Director of Nursing (DON)

the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents revised 7/2017, was reviewed. The P&P indicated the facility will implement interventions to reduce accident risks and hazards by communicating specific interventions to all relevant staff and to ensure interventions are implemented. The DON stated a staff member should ' ve been provided to be with Resident 1 and hand off communication between the staff member leaving and RN 1 should ' ve been better. The DON stated the P&P was not followed and stated the incident could ' ve been prevented if staff knew of Resident 1 ' s behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 555854

F-F689

Findings:

a. During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] 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 REDACTED] and readmitted on [DATE REDACTED] 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 REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 555854 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview on 1/7/2025 at 4:36 PM with the Director of Nursing (DON), the DON stated the purpose of the SBAR is to identify changes of condition. The DON further stated the risk of not completing an SBAR Level of Harm - Minimal harm or was that there would be no documentation of Medical Doctor (MD) notification and staff could miss an MD potential for actual harm order or fail to do an assessment on the resident.

Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status revised 11/2015, the P&P indicated the nurse supervisor or charge nurse will notify the resident ' s physician or on-call physician when there has been an accident or incident involving the resident. The P&P indicated prior to notifying the MD, the nurse will gather relevant and pertinent information for the provider prompted by the SBAR Communication Form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 555854 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48905

Residents Affected - Few Based on interview and record review, the facility failed to implement the facility ' s policy titled Safety and Supervision of Residents and supervise one of five sampled residents (Resident 1) when Resident 1 verbalized having feelings of hurting Resident 5 on 12/31/2024 at 5 PM.

This failure resulted in Resident 1 entering Resident 5 ' s room without permission, engaging in a verbal altercation with Resident 5, and attempting to throw items towards Resident 5 on 12/31/2024.

Cross reference