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.

Health Inspection: Mesa Glen Care Center

FF600

Actual harm but cannot make medical decisions. Few During a review of Resident 37's Minimum Data Set (MDS, a resident assessment and care planning tool) affected

During a review of Resident 37's Admission Record (AR), the AR indicated the facility initially admitted Resident 37 on 10/11/2024 and readmitted on [DATE] with diagnoses that included Huntington's Disease (HD, a progressive and genetic [inherited] disorder that affects the brain), and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning).

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 03/07/2025

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

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

FF699

Minimal harm or traumatic event, such as a gunshot wound, but could not provide any further specifics. CNA 13 stated that Few affected

During a review of Resident 47's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/6/2025, the MDS indicated Resident 47's cognition (the ability to think and process information) was intact.

The MDS indicated Resident 47 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance with mobility.

During an interview on 3/4/2025 at 11:48 AM, with Resident 47, Resident 47 stated that she had been living at the facility for a while, and overall, the care had been fine. Resident 47 stated there was something she had been struggling with, and that was the lack of understanding when it came to her PTSD diagnosis. Resident 47 stated that she had difficult experiences in her past, and her PTSD had affected the way she interacted with people or handled certain situations. Resident 47 stated that it felt like no one at the facility really understood her or knew how to respond to her triggers. Resident 47 stated that when staff approached her in a certain way or when someone came too close too quickly her body went into fight or flight (an automatic, instinctive reaction to perceived danger or stress, preparing the body to either confront the threat [fight] or escape [flight]) mode, and she could not control it. Resident 47 stated that when she acted out, whether it was getting upset or withdrawing into herself, it seemed like the staff just thought she was being difficult or acting out for no reason. Resident 47 stated that if staff had a little more awareness of her condition, it would go a long way and make a significant difference.

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 03/07/2025

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

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

FF726

Minimal harm or traumatic event, such as a gunshot wound, but could not provide any further specifics. CNA 13 stated that Few affected

During a review of Resident 47's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/6/2025, the MDS indicated Resident 47's cognition (the ability to think and process information) was intact.

The MDS indicated Resident 47 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required supervision or touching assistance with mobility.

During an interview on 3/4/2025 at 11:48 AM, with Resident 47, Resident 47 stated that she had been living at the facility for a while, and overall, the care had been fine. Resident 47 stated there was something she had been struggling with, and that was the lack of understanding when it came to her PTSD diagnosis. Resident 47 stated that she had difficult experiences in her past, and her PTSD had affected the way she interacted with people or handled certain situations. Resident 47 stated that it felt like no one at the facility really understood her or knew how to respond to her triggers. Resident 47 stated that when staff approached her in a certain way or when someone came too close too quickly her body went into fight or flight (an automatic, instinctive reaction to perceived danger or stress, preparing the body to either confront the threat [fight] or escape [flight]) mode, and she could not control it. Resident 47 stated that when she acted out, whether it was getting upset or withdrawing into herself, it seemed like the staff just thought she was being difficult or acting out for no reason. Resident 47 stated that if staff had a little more awareness of her condition, it would go a long way and make a significant difference.

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 03/07/2025

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

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

FF758

Minimal harm or did not have Resident 5's signature. RN 4 stated Informed Consent is completed upon admission. RN 4 Few Lorazepam medication was not signed by Resident 5. RN 4 stated if the Informed Consent was not signed, affected

During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 12/24/24, the MDS indicated Resident 5 was cognitively intact (ability to understand and process thoughts), and required partial/moderate assistance with personal hygiene and upper body dressing and substantial/maximal assistance with lower body dressing.

During a review of Resident 5's History & Physical (H&P), dated 2/28/25, the H&P indicated Resident 5 had the capacity to make medical decisions.

During a record review of Resident 5's Physician Orders (PO), the PO indicated Resident 5 was given Olanzapine oral tablet 2.5 milligrams (mg), one tablet, by mouth, two times a day (BID) for schizoaffective disorder (schizophrenia- [a disorder affecting a person's ability to think, feel, and behave] and mood disorder [psychiatric conditions causing intense and persistent changes in mood, energy, and behavior]) manifested by (m/b) verbal aggression toward others.

During an interview on 3/7/25, at 10:00 a.m., Resident 5 stated facility staff tried to give her a pill this morning, and Resident 5 refused to take the pill. Resident 5 stated Resident 5 has not signed nothing about medication. Resident 5 stated Resident 5 does not have schizophrenia and does not need the medication.

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 03/07/2025

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

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

FF801

Minimal harm or milk were observed with no received date. No opened dates were observed on opened muffin mixes, Some canister. A bag of undated grilled cheese and chicken pozole with a use by date of 2/27/2025 was observed affected

During an interview on 3/4/2025 at 10:05 AM with dishwasher 1 (DW 1), DW 1 stated DW 1 did not check the chlorine ppm in the morning before washing the dishes. DW 1 stated DW 1 does not check the chlorine ppm levels and does not know what the chlorine was used for in the dishwashing machine.

During a concurrent observation and interview on 3/4/2025 at 10:34 AM with the DS and the Registered Dietician (RD), the dishwasher's chlorine ppm was checked.

The chlorine ppm strip indicated a result of zero (0) ppm.

The DS stated the chlorine ppm should be between 50 to 100 ppm and stated the staff should be checking the chlorine ppm to ensure the dishwasher was sanitizing the dishes.

The DS stated by not checking the chlorine ppm the dishes would not be sanitized.

During an interview on 3/4/2025 at 2:46 PM with the DS, the DS stated the chloring tubing for the dishwasher was placed into the tub correctly.

The DS stated the if the tubing is not placed correctly for the chlorine solution, then the dishwasher would not be able to properly sanitize the dishes.

During a concurrent interview and record review on 3/7/2025 at 8:45 AM with the DS, the facility's Daily Dishwasher Chlorine and Temperature Log (DDCTL) dated 3/2025 was reviewed.

The DDCTL indicated the chlorine ppm to be 200 on 3/1/2025, 3/4/2025, and 3/5/2025.

The DDCTL indicated blank spaces on 3/2/2025 and 3/3/2025.

The DS stated the chlorine level was not in the correct range on 3/1/2025, 3/4/2025, and 3/5/2025.

The DS stated there were blank spaces on 3/2/2025 and 3/3/2025 and this would indicate the dishwasher's wash temperature and chlorine ppm was not checked.

The DS stated the out-of-range levels for chlorine ppm was not reported to the DS.

The DS stated if it was not reading the right chlorine ppm level it should've been reported to the DS for further investigation.

The DS stated staff would need an in-service on how to properly manage the kitchen's dishwasher.

During a review of the facility's undated, policy and procedure (P&P) titled, Labeling and Dating of Foods Policy, the P&P indicated all food items must be labeled with the date received.

The P&P indicated any food without a label or past its discard date must be thrown away immediately.

During a review of the facility's undated, P&P titled, Dishwashing the P&P indicated the chlorine should read 50 to 100 ppm and indicated if unable to reach the chlorine level to resort to manual method of dishwashing.

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 03/07/2025

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

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

Mesa Glen Care Center

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