Mesa Glen Care Center

F-F842

Findings:

During a review of Resident 1 ' s Admission Record (AR), dated 4/15/2025, the AR indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including toxic encephalopathy (brain dysfunction caused by exposure to harmful substances) and depression (a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life). The AR indicated Family Member (FM) 1 was Resident 1 ' s responsible party.

During a review of Resident 1 ' s History and Physical (H&P- a medical exam that involves a doctor gathering

a patient ' s medical history and performing a physical exam), dated 2/21/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.

During a review of Resident 1 ' s Minimum Data Set (MDS-a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 1's was cognitively intact (the ability to think and process information).

During a review of Resident 1 ' s care plans (CP), Resident 1 did not have a care plan for Resident 1's diagnosis of hypotension.

During a review of Resident 1's Physician Order Summary Report (POSR), dated 3/1/2025, the POSR indicated to monitor Resident 1 for orthostatic hypotension one time a day every Sat (Saturday), starting on 3/8/2025.

During a review of Resident 1 ' s Medication Administration Record (MAR- provides a comprehensive, organized record of each medication administered to a patient), dated 3/8/2025, at 6:00 a.m., the MAR indicated to monitor Resident 1 for orthostatic hypotension one time a day every Sat, with start date 3/8/2025. The MAR indicated no documentation of monitoring on 3/8/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 555854 Department of Health & Human Services Printed: 08/29/2025 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 04/15/2025

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 0726 During a concurrent interview and record review on 4/14/2024 at 12:40 pm with LVN 1, the facility's Job Description, LVN dated 3/12/2021 were reviewed. LVN 1 stated LVN 4 did not follow the facility's job Level of Harm - Minimal harm or description. The Job Description indicated LVN s are responsible for providing direct nursing care to the potential for actual harm residents and supervision of nursing activities performed by nursing assistants in accordance with current federal, state, and local standards, guidelines and regulations and company policies and procedures to Residents Affected - Few ensure that the highest degree of quality care is maintained at all times. LVN 1 stated the Job Description indicated to perform documentation responsibilities in accordance with company requirements. The Job Description indicated to LVNs (in general) were to completes accurate, thorough and timely admission records, routine resident observations/transfer notes, death/discharge summaries and changes in resident condition in accordance with facility policies and procedures. LVN 1 stated LVN 4 by not document Resident 1's BP. LVN 1 stated if there was no documentation, then the assessment was not done.

During a concurrent interview and record review on 4/15/2025 at 4:00 pm with the DON, the facility's Job Description, RN dated 3/12/2021 were reviewed. The DON stated the RNs (in general) did not follow the job description by not completing the documentation and not providing Resident 1 with the order given by physician for orthostatic BP every Saturday starting 3/8/2025. The DON stated the Job Description indicated RNs are to plan and deliver nursing care to residents in skilled nursing in accordance with current company, federal, state and local standards, guidelines and regulations to ensure that the highest degree of quality care and dignity is maintained at all ties. The DON stated the Job Description indicated RNs are to perform documentation duties as required and in accordance with company charting and documentation policies and procedures and government regulations. The DON stated the Job Description indicated RNs were to ensure documentation is accurate, timely and descriptive of resident ' s condition, nursing care provided and resident ' s response to care. The DON stated LVN 4 and RN 1 needed more training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 555854