Mesa Glen Care Center

During a record review of the facility's Policy & Procedure (P&P) titled, Psychoactive Medication

prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided.

The P&P indicated before initiating treatment with psychotherapeutic drugs, facility staff shall verify that the resident's health record contains written informed consent with the required signatures.

555854 03/07/2025

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

During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was readmitted to the facility on [DATE] with diagnoses that included epilepsy (a brain disorder that causes recurring, unprovoked seizures) and osteoporosis (weak and brittle bones).

During a review of Resident 20's History and Physical (H&P), dated 3/4/2024, the H&P indicated Resident 20 had a fluctuating capacity to understand and make decisions.

During a review of Resident 20's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment, dated 1/22/2025, the MDS indicated Resident 20 had intact cognition (ability to understand) and needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) for upper body dressing (to dress and undress above the waist).

During an observation on 3/4/2025 at 11:23 am in Resident 20's room, Resident 20 was sitting up in bed with the call light wire behind a pillow and the call light touching the floor.

During a concurrent observation and interview on 3/4/2025 at 11:27 am with Licensed Vocational Nurse 2 (LVN 2) inside Resident 20's room, the call light was observed touching the floor. LVN 2 stated, the resident's call light should not be under the pillow or touching the ground because Resident 20 needed it close by to call for assistance.

During an interview on 3/7/2025 at 9:21 am with the Director of Nursing (DON), the DON stated, Resident 20's call light should be within reach, in case the resident needs to call for help.

The DON further stated if the resident cannot reach the call light, they may not get the help they need, putting them at risk for injury.

During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, last revised 9/2022, the P&P indicated, the purpose was to ensure timely responses to the resident's requests and needs.

The P&P indicated as a general guideline; the call light was accessible to the resident when in bed.

555854 03/07/2025

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

During a review of Resident 11's history and physical (H&P) dated 1/21/2025, the H&P indicated Resident 11 had the capacity to understand and make decisions. g.

During a review of Resident 37's admission Record (AR), the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Huntington's Disease (HD, genetic brain disorder that causes slow progressive decline in movement, thinking, and emotional abilities), Human Immunodeficiency Virus (HIV, virus that attacks the body's immune system) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday tasks).

During a review of Resident 37's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 2/3/2025 indicated Resident 37 can make needs known but cannot make medical decisions.

During a review of Resident 37's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 2/7/2025, indicated Resident 37's had moderately impaired cognitive abilities (ability to think, learn, and process information).

During a concurrent interview and record review on 3/5/2025 at 9:32 AM with the Social Services Director (SSD), Resident 11 and 37's Advance Directive Acknowledgement (ADA) form was reviewed.

The SSD stated Resident 11 and 37's ADA forms were not filled out completely and stated the form should be filled completely within 24 hours of admission.

The SSD stated by not having the ADA forms filled out completely would place residents at risk of receiving the incorrect emergency treatment.

During an interview on 3/7/2025 at 1:46 PM with the Director of Nursing (DON), the DON stated the ADA form should be filled out immediately upon admission.

The DON stated by not filling out the form completely places the resident at risk of providing the wrong emergency treatment and not honoring the resident's wishes.

During a review of the facility's policy and procedure (P&P) titled, Advance Directives revised 9/2022, the P&P indicated prior to admission of a resident, the SSD or designee will inquire about the existence of any written advance directives.

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

environment.

The P&P indicated, staff provided person-centered care that emphasized the resident's

555854 03/07/2025

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

immediately report allegations of abuse to the state licensing and certification agency within two

555854 03/07/2025

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

During a review of Resident 2's admission Record (AR), the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous growth of cells) of the stomach and prostate (small gland in male reproductive system).

During a review of Resident 2's Health Status Note (HSN) dated [DATE] at 10:08 PM, the HSN indicated Resident 2 expired on [DATE] at 11:08 PM.

During a review of the MDS 3.0 NH Final Validation Report (FVR) dated [DATE], the FVR indicated Resident 2's MDS was submitted on [DATE] and indicated it was submitted past 14 days after Resident 2's death.

During an interview on [DATE] at 12:02 PM with the MDS Assistant (MDS A), the MDS A stated Resident 11 expired on [DATE] and stated the MDS was not submitted until [DATE]. MDS A stated the purpose of submitting the MDS timely was to ensure information was accurate and to follow Medicare guidelines.

During an interview on [DATE] at 2:07 PM with the Director of Nursing (DON), the DON stated a resident's MDS needs to be submitted within 14 days.

The DON stated if it was not submitted within the 14 days it would put the facility at risk of not being compliant with regulations.

During a review of the facility's policy and procedure (P&P) titled, CMS's RAI Version 3.0 Manual dated 10/2023, the P&P indicated for a death in the facility tracking record needs to be transmitted within 14 calendar days.

555854 03/07/2025

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

During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revision 3/2022, the P&P indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

555854 03/07/2025

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

During an interview on 3/05/25, at 12 PM, Resident 49 stated Resident 49 has a sore on her bottom.

During an observation of Resident 49 on 3/06/25 12:10 PM, Resident 49 was sleeping in bed in a supine position.

During in interview on 3/6/25, at 12:15 PM with the Director of Nurse (DON) there was no weekly skin assessments for Resident 49.

The DON stated it is the facility policy to complete weekly assessment and as needed for residents.

During an interview on 3/07/25, at 11:24 AM TN 1, TN 1 stated all licensed nurses could perform a head-to-toe assessment, but It is the treatment nurse primary responsibility. TN 1 stated the last skin assessment for Resident 49 dated 12/27/24 following the resident's readmission. TN 1 stated It is important to follow facility policy and complete regular skin assessments so that staff know if the treatment is effective.

During an interview on 3/07/25, at 12:00 PM, TN 1 stated she was unable to provide monitoring documentation about Resident 49's skin conditions.

555854 03/07/2025

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

During an interview on 3/7/2025 at 11:08 AM, with the Director of Nursing (DON), the DON stated that the correct settings on a LALM was essential to providing the best care for residents, particularly those who were at higher risk for pressure ulcers or skin breakdowns.

The DON stated that the LALM was designed to redistribute pressure, reduce friction, and provide constant airflow to the skin, which was particularly important for immobile or frail residents.

The DON stated that if the settings was not accurate, the mattress might not provide the necessary support and airflow, which could lead to discomfort and, in some cases, exacerbate pressure related injuries.

During a review of the facility's user manual titled, Med Aire 10 Alternating Pressure and Low Air Bariatric Mattress Replacement System, undated, the user manual indicated, It is recommended to press Auto Firm on the panel when the mattress is first inflated.

Users can then easily adjust the air mattress to desired firmness according to patient's weight and comfort.

555854 03/07/2025

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

During an interview on 3/5/2025 at 12:29 PM, with Certified Nursing Assistant (CNA) 4, CNA 4 stated that Resident 294 was confused and dependent on staff for eating. CNA 4 stated that she was notified of Resident 294's fall but did not witness the fall as she was passing out meal trays at the time. CNA 4 stated that Resident 294's meal tray should not be placed on Resident 294's bedside table, given the resident's confusion and fall risk. CNA 4 stated that Resident 294's tray should not be delivered to Resident 294's room until staff were ready to assist Resident 294 with his meal, as this would have helped prevent the fall.

During an interview on 3/7/2025 at 11:08 AM, with the Director of Nursing (DON), the DON stated that residents who were cognitively impaired often lacked the awareness of their surroundings or their physical capabilities.

The DON stated if the meal tray was within reach and a cognitively impaired resident was not being supervised or assisted, they may attempt to grab it, which could lead to a fall, as the facility unfortunately experienced with Resident 294.

The DON stated that Resident 294's confusion and inability to recognize the potential hazard were significant factors in the fall incident.

The DON stated that staff should not deliver a meal tray to a confused and dependent resident unless staff were ready to assist with feeding.

The DON stated the meal tray should only be placed in the resident's vicinity when staff were present to help the resident with the meal.

The DON stated this would ensure that the resident was not left in a vulnerable state where the resident might reach for the tray on his/her own.

During a review of the facility's P&P titled, Safety and Supervision of Residents, revise 7/2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible.

Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

The P&P indicated, The facility-oriented approach and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .

Resident supervision is a core component of the systems approach to safety.

The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

The P&P indicated, The type and frequency of resident supervision may vary among residents and over time for the same resident.

For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in resident's condition.

555854 03/07/2025

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

During an interview on 3/7/2025 at 1:40 PM with the Director of Nursing (DON), the DON stated nursing staff are to monitor the patency of the FC and check for placement and sediments every shift.

The DON stated if it was not done then it would put the resident at risk for developing an infection.

During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary revised 8/2022, the P&P indicated the date and time catheter care was given will be recorded into the resident's medial record.

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

During an interview on 3/7/2025 at 1:42 PM with the Director of Nursing, the DON stated if a resident

place the resident at risk of further weight loss because interventions would not be ordered to address the weight loss if it was medically related.

During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention revised 9/2008, the P&P indicated the physician, and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing weight loss.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status revised 2/2021, the P&P indicated the nurse will notify the MD when there has been a significant change in the resident's physical, emotional, and or mental condition.

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

During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.

The P&P indicated, The following equipment and supplies will be necessary when performing this procedure .

Place an Oxygen in Use sign on the outside of the room entrance door.

The P&P indicated, Verify that there is a physician's order for this procedure.

Review the physician's orders or facility protocol for oxygen administration.

During a review of the facility's P&P titled, Medication Orders, revised 11/2014, the P&P indicated, When recording orders for oxygen, specify the rate flow, route and rationale.

Example: oxygen 3L/min per nasal cannula as needed for shortness of breath.

555854 03/07/2025

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

During an interview on 3/7/2025 at 1:58 PM with the Director of Nursing (DON), the DON stated Resident 5's complaint of pain (pain scale) should have been communicated to the attending physician.

The DON stated by not communicating Resident 5's concern to the physician placed Resident 5 at risk for not reaching the maximal potential for pain relief.

During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised 10/2022, the P&P indicated pain management was a multidisciplinary care process that includes developing and implementing approaches to pain management and monitoring effectiveness of interventions.

555854 03/07/2025

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

During a review of Resident 62's admission Record (AR), the AR indicated Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease (ESRD, occurs when kidney function has declined to the point the kidneys can no longer function on own) and dependence on dialysis.

During a review of Resident 62's History and Physical (H&P) dated 11/14/2024, the H&P indicated Resident 62 had the capacity to understand and make decisions.

During a review of Resident 62's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 12/14/2024, the MDS indicated Resident 62's cognitive abilities (ability to think, learn, and process information) was intact.

During a review of Resident 62's Order Summary Report (OSR) dated 1/31/2025 indicated Resident 62 had an active Medical Doctor (MD) order for dialysis on Tuesday, Thursday, and Saturday.

During a concurrent interview and record review on 3/5/2025 at 2:38 PM with Licensed Vocational Nurse 2 (LVN) 2, Resident 62's Post Dialysis Assessment (PDA) form dated 3/1/2025 was reviewed.

The PDA form contained blank spaces for the PDA section. LVN 2 stated the pre and post assessments for dialysis need to be filled out when a resident goes out of the facility to receive dialysis. LVN 2 stated the PDA form was left blank. LVN 2 stated by not filling out the PDA form this placed Resident 62 at risk for not monitoring for unstable vital signs or risk of bleeding at the catheter site after dialysis.

During an interview on 3/7/2025 at 1:53 PM with the Director of Nursing (DON), the DON stated the pre and post dialysis assessment should be filled out to monitor for any complications before and after dialysis.

The DON stated if the form was not filled out, the status of the resident would be unknown, and the staff would not have any documentation on the baseline vital signs or any monitoring of the access site.

During a review of the facility's P&P titled, Hemodialysis Catheters-Access and Care of revised 2/2023, the P&P indicated the nurse should document observations post dialysis every shift.

555854 03/07/2025

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

During an interview on 3/7/2025 at 10:08 AM, with the Director of Staff Development (DSD), the DSD stated that the DSD was unaware of any residents with a diagnosis of PTSD in the facility.

The DSD emphasized the importance of staff awareness regarding PTSD, as it affected how individuals responded to their environment, processed emotions, and interacted with others.

The DSD stated that without an understanding of the signs and triggers of PTSD, staff might misunderstand certain behaviors, which could lead to frustration or ineffective support.

The DSD stated that being mindful of PTSD ensured that the facility approached each resident with empathy and patience, fostering a safe and supportive environment.

The DSD stated that staff had not been in-serviced on specific PTSD related topics.

The DSD stated that incorporating PTSD in the in-service lesson plan would help staff stay current with best practices and ultimately create an environment of understanding and compassion, benefiting everyone.

During an interview on 3/7/2025 at 11:08 AM, with the Director of Nursing, the DON stated that PTSD awareness was critical in the facility because it directly impacted the care provided to residents.

The DON mentioned that many residents who entered the facility had experienced some form of trauma.

The DON stated that PTSD could affect both the resident's emotional and physical health, and without awareness of the signs and symptoms, there was a risk of misinterpreting the resident's behavior.

The DON stated that by offering regular, PTSD specific in-services, the facility would ensure that all staff members understood PTSD and how it manifested.

The DON stated that this type of training, benefited everyone who had direct contact with residents, enabling staff to approach residents with sensitivity and compassion.

The DON stressed the importance of creating an environment that supported healing and reduced potential triggers.

During a review of the facility's policies and procedures titled, Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated,

• The facility will provide, and residents will receive behavioral health services as needed to attain or

maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

• Behavioral symptoms will be identified using facility-approved behavioral screening tools and the

comprehensive assessment.

• Behavioral health services will be provided by qualified staff who have the competencies and skills

necessary to provide appropriate services to the residents.

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

Competent Nursing, revised August 2022, the P&P indicated our facility provides sufficient numbers of

revised October 2010, the P&P indicated the purpose of this procedure is to respond to the resident's request and needs.

The P&P indicated for staff to answer the resident's call light as soon as possible.

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

necessary to provide appropriate services to the residents.

555854 03/07/2025

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

During an interview on 3/7/2025 at 5:35 PM with the Director of Staff Development (DSD), the DSD stated the Staffer posts the actual nursing hours in the Lobby and South Station, however, the NOC shift was not posted.

The DSD stated if the NOC shift actual hours were not posted staff, family members, visitors, and residents would not know how many staff members are working that day.

During an interview on 3/7/2025 at 5:41 PM with the Staffer, the Staffer stated the NOC shift was supposed to post the actual nursing hours for the NOC shift, but it was not done and would need training on how to post the actual nursing hours.

The Staffer stated if the actual nursing hours are not posted for the NOC shift, nurses, residents, and families would not know how many staff members are working.

During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing revised 8/2022, the P&P indicated direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.

During a review of Resident 27's admission Record (AR), the admission Record indicated Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute osteomyelitis (bone infection caused by bacteria) of the left foot and ankle and cellulitis (serious bacterial skin infection).

During a review of Resident 27's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 1/10/2025, the MDS indicated Resident 27's cognitive abilities (ability to think, learn, and process information) were intact.

During a review of Resident 27's Order Summary Report dated 2/19/2025 indicated Resident 27 had an MD order for Zosyn 3.375 gram IV every eight hours for osteomyelitis to the left third toe and status post Incision and Drainage (I&D, medical procedure used to relieve pressure and treat infections to drain out pus or fluids in an infected area) until 3/26/2025. On 2/20/2025 the OSR indicated an active MD order for Daptomycin 700 milligrams (mg, unit of measurement) IV once a day for osteomyelitis of the left third toe until 3/26/2025.

During a review of Resident 27's History and Physical (H&P) dated 2/20/2025, the H&P indicated Resident 27 had the capacity to understand and make decisions.

During a concurrent interview and record review on 3/6/2025 at 11:34 AM with Registered Nurse Supervisor 4 (RN 4), Resident 27's Intravenous Medication Administration Record (IMAR) dated 2/2025 to 3/2025 was reviewed. RN 4 stated there were blank spaces for Zosyn administration on 2/21/2025, 2/25/2025, and 3/1/2025. RN 4 stated there were blank spaces for Daptomycin administration on 2/23/2025, 2/26/2025, and 3/1/2025. RN 4 stated if it was blank then the medication was not given as ordered. RN 4 stated if antibiotics were not given as ordered it would place the resident at risk of worsening the current infection or develop a new infection.

During an interview on 3/7/2025 at 1:38 PM with the Director of Nursing (DON), the DON stated if the IMAR was blank then it was missed.

The DON stated the resident needs to receive antibiotics as ordered to treat the current infection and prevent future infections.

The DON stated if the resident did not receive the antibiotics as prescribed it can place the resident at risk of worsening the current infection or the infection can become resistant to the antibiotic.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines dated 3/2024, the P&P indicated the individual who administered the medication dose shall record the administration in the resident's MAR directly after the medication was given.

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

stated inform consent is a part of the resident rights.

Informed Consent, dated, March 2024, indicated before prescribing a psychotherapeutic drug, the

resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided.

The P&P indicated before initiating treatment with psychotherapeutic drugs, facility staff shall verify that he resident's health record contains written informed consent with the required signatures.

555854 03/07/2025

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

During an interview on 3/7/2025 at 2:04 PM with the Director of Nursing (DON), the DON stated staff must check the dose prior to administering a medication.

The DON stated it would be a medication error because the wrong dose was almost administered to Resident 13.

The DON stated the HR needs to be checked prior to administering Amlodipine and Metoprolol.

The DON stated staff need to follow the parameters of the medication and if it was not followed it could cause harm to the resident.

During a review of the facility's policy and procedure (P&P) titled, Administering Medication revised 4/2019, the P&P indicated medications are to be administered in a safe, timely manner, and as prescribed.

The P&P indicated the individual administering the medication must check the label three times to verify the right resident, medication, dosage, time, and method of administration before giving the medication.

555854 03/07/2025

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

During a concurrent observation and interview on 3/6/2025 at 8:45 AM with Licensed Vocational Nurse (LVN 4) in Resident 26's room, LVN 4 was observed to place the medicine cup with metoprolol and amlodipine in front of Resident 26 without taking the HR and stated to Resident 26, Okay, take your medications. LVN 4 stated the heart rate was not checked prior to administering Metoprolol and Amlodipine. LVN 4 stated by not checking the heart rate LVN 4 could've administered both medications when the heart rate could've been too low per MD parameters.

During a concurrent interview and record review on 3/6/2025 at 11:34 AM with Registered Nurse Supervisor 4 (RN 4), Resident 27's Intravenous Medication Administration Record (IMAR) dated 2/2025 to 3/2025 was reviewed. RN 4 stated Zosyn was not administered on 2/21/2025, 2/25/2025, and 3/1/2025. RN 4 stated Daptomycin was not administered on 2/23/2025, 2/26/2025, and 3/1/2025. RN 4 stated if the IMAR was blank then the medication was not given as ordered. RN 4 stated if antibiotics were not given as ordered it could worsen the current infection or put the resident at risk of developing a new infection.

During an interview on 3/7/2025 at 1:38 PM with the Director of Nursing (DON), the DON stated if the IMAR was blank then the antibiotics were not given.

The DON stated if the resident did not receive the antibiotics as prescribed it could worsen the current infection or the infection can become resistant to the antibiotic. At 2:04 PM, the DON stated the HR needs to be checked prior to administering Amlodipine and Metoprolol.

The DON stated staff need to follow the parameters of the medication and if it was not followed it could cause harm to the resident.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines dated 3/2024, the P&P indicated medications are to be administered in accordance with written orders of the attending physician.

555854 03/07/2025

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

During a concurrent observation and interview on 3/4/2025 at 9:49 AM with the Dietary Supervisor (DS) while in the kitchen, the chlorine parts per millions (ppm, unit of a concentration of chlorine in water that is used for sanitation) was checked.

The DS stated the strip indicated the ppm was at zero and it should be at 100 ppm.

During an interview on 3/4/2025 at 10:05 AM with DW 1, DW 1 stated DW 1 did not check the chlorine ppm in the morning prior to washing the dishes. DW 1 stated DW 1 does not check the chlorine ppm and does not know what the chlorine is used for in the dishwashing machine. DW 1 stated DW 1 never checks the chlorine ppm in the morning and has been working mornings in the kitchen for the last three months.

During an interview on 3/7/2025 at 9:30 AM with the DS, the DS stated there were no in-services provided to dietary staff for sanitizing and dishwashing practices.

The DS stated there were no in-services provided in 2024 and only a couple in 2023.

The DS stated there should have been in-services provided and stated if in-services were not provided to staff, then staff would not know the proper and current practices for sanitizing and handling equipment.

During a review of the facility's policy and procedure (P&P) titled, Staff Development dated 2023, the P&P indicated the food and nutrition services staff will be in-service at least monthly by the food and nutrition services director or the registered dietician.

555854 03/07/2025

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

During a concurrent observation and interview on 3/4/2025 at 10:34 AM with the DS and the

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.

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

555854 03/07/2025

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

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

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

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

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

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