Mesa Glen Care Center

F 0550 Level of Harm - Minimal harm or potential for actual harm

8/11/2025, the MDS indicated Resident 8 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, personal hygiene, sitting to lying and lying to sitting on the side of bed.

Residents Affected - Some

During an observation on 8/29/2025 at 12:18 PM in Resident 8's room, a staff was observed standing at Resident 8's bedside and assisting the resident to eat.

During an interview on 8/29/2025 at 12:31 PM with Resident 8, Resident 8 stated that Resident 8 would feel staff were maintaining Resident 8's dignity if the staff had been sitting at the same level as the resident while assisting to eat.

During an interview on 8/29/2025 at 12:38 PM with Certified Nurse Assistant (CNA) 2, CNA 2 confirmed CNA 2 was standing at Resident 8's bedside while assisting the resident to eat. CNA 2 stated that she should sit at the same level as the resident to maintain the resident's dignity when assisting the resident to eat.

During a review of the facility's Policy and Procedure (P&P) titled, “Dignity,” revised February 2021, the P&P indicated, “Residents are treated with dignity and respect at all times.” The P&P indicated that “When assisting with care, residents are supported in exercising their rights. For example, Residents are: e. provided with a dignified dining experience.”

During a review of the facility's P&P titled, “Assistance with Meals,” revised March 2022, the P&P indicated, “Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals; b. Keeping interactions with other staff to a minimum while assisting residents with meals; c. Avoiding the use of labels when referring to residents (e.g., feeders); and d. Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to follow their Change in a Resident's Condition or Status policy and procedure to notify one of three sampled residents (Resident 7's) doctor of Resident 7's weight loss on 7/1/2025.These failures had the potential to result in Resident 7 to not receive treatment to address Resident 7's weight loss which could negatively affect Resident 7's health and wellbeing. (Cross Reference F-F550, F-F689, and F-F755)Findings:During a review of Resident 7's admission Record (AR), the AR indicated Resident 7 was admitted to the facility on [DATE REDACTED] with diagnoses including multiple fractures (broken bone) of ribs, hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), urinary tract infection (UTI- an infection in the bladder/urinary tract), and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function).During a review of Resident 7's Progress Notes (PN), dated 7/9/2025, the PN indicated the resident had experienced a significant unintentional weight loss of 17 LBs (11.8%) over

the past 30 days. According to the PN the resident's weight decreased from 144 LBS on 6/9/2025 to 127 LBs on 7/7/2025.During a review of Resident 7's History and Physical (H&P), dated 7/16/2025, the H&P indicated that the resident had capacity to make medical decisions.During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 7 was moderately impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 7 required substantial to maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. The MDS indicated the resident required partial/moderate assistance (helper does less than half

the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing.During a review of the facility's Weight Summary Report (WSR), dated 8/29/2025, the WSR indicated Resident 7 weighed 144 pounds (LB, a unit of measurement) 90 days prior. The WSR indicated Resident 7's weight was 118 LBs for week 8/22/2025. The MSR indicated Resident 1 had a more than ten percent (10%) weight loss in less than 180 days on 7/1/2025.During a concurrent interview and record

review on 9/2/2025 at 4:10 PM with Registered Nurse (RN) 1 and the Director of Nursing (DON), Resident 7's Change in Condition Evaluation (CICE), for June, July, and August 2025 were reviewed. The DON confirmed there was no CICE for a significant unintentional weight loss to notify the resident's doctor in June, July, and August 2025. The DON stated the facility should create a CICE for the resident's significant weight loss.During a review of the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, the P&P indicated that the nurse will notify the resident's attending physician or on call physician when there has been a significant change in the resident's physical/emotional/mental condition. During a review of the facility's P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised September 2017, the P&P indicated, the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. During a review of the facility's P&P titled, Weighing and Measuring the Resident, revised March 2011, the P&P indicated, report significant weight loss/weight gain to the nurse supervisor. The P&P indicated that the threshold for significant unplanned and undesired with loss/gain will be based on the following criteria:a. 1 month - 5% weight loss is significant; greater than 5% is severe.b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe.c. 6 months - 10% weight loss is significant; greater than 10% is severe.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review, the facility failed to honor the privacy (a resident's right to be free from observation including the resident's private space) and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure) of one of one sampled resident (Resident 13) when a video recording (Video 1) of Resident 13's room was posted to TikTok (a social media app where people create and share short videos).This failure resulted in the violation of Resident 13's right to privacy and confidentiality and had the potential to result in Resident 13 experiencing emotional distress and feelings of decreased self-worth.Findings:During

a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted Resident 13 on 3/4/2025 and readmitted Resident 13 on 6/27/2025 with diagnoses including hereditary (a disease passed down from a person's parents) and idiopathic (a disease of unknown cause) neuropathy (nerve damage or disease leading to pain, numbness, tingling, or muscle weakness) and dementia (the loss of the ability to think, remember, and reason that affect daily life and activities).During a review of Resident 13's History and Physical (H&P), dated 7/24/2025, the H&P indicated Resident 13 had fluctuating (changing in

an unstable or unpredictable way) capacity to understand and make decisions.During an observation on 8/29/2025 at 12:20 PM Video 1, dated 7/7/2025, was observed on TikTok. Video 1 recorded Certified Nursing Assistant (CNA) 1 sitting in a resident's room with a resident's personal property and pictures in

the background. Additionally, Video 1 recorded a view into four other (unidentified) resident rooms.During

an interview on 8/29/2025 at 1:34 PM with CNA 1, CNA 1 stated Video 1 was a recording of CNA 1 sitting

in Resident 13's room and was recorded by LVN 1.During an interview on 8/29/2025 at 1:58 PM with the Director of Nursing (DON), the DON stated Video 1 was recorded at the facility. The DON stated recording TikTok videos was not allowed at the facility because it violated the residents' rights to privacy and confidentiality.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 2001, revised February 2021, the P&P policy statement indicated, Employees shall treat all residents with kindness, respect, and dignity. The P&P policy interpretation and implementation indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.During a review of the facility's P&P titled, Confidentiality of Information and Personal Privacy, dated 2001, revised October 2021, the P&P policy statement indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The P&P policy interpretation and implementation indicated, Release of resident information, including video, audio, or computer stored information, will be handled in accordance with resident rights and privacy policies.During a review of the facility's employee handbook titled, California Employee Handbook, dated 2024-2025, the handbook's social media guidelines indicated, These guidelines apply to all Facility employees who participate in any form of personal social networking including, but not limited to Facebook, Twitter, Instagram, TikTok, Snap Chat, LinkedIn, Yelp or any other social networking sites. Except when expressly authorized in writing for use for business purposes, social media activities are not permitted at work or while on Facility time.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with hard half splint with ACE wrap daily for immobilization purposes every day shift.During a review of the facility's P&P titled, Pain: Assessment and Management dated October 2022, the P&P indicated the following under Steps in the Procedure:1. Recognizing Pain, #4 indicated Ask the resident if he/she is experiencing pain.2. Assessing Pain #1 indicated Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for who pain may be anticipated

during specific procedures, care, or treatment; and #4 indicated, Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.During a

review of the facility's P&P titled, admission Criteria, dated March 2019, the P&P indicated the following:1.

The objectives of our admission criteria policy are to: (b) admit residents who can be cared for adequately by the facility. 2. Examples of nursing/medical needs that can be met adequately include: (a) medication management and (b) limited mobility. 3. All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid Pre-admission Screening and Resident Review process. Item (e) The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, dated September 2012, the P&P indicated, the purpose of this procedure, is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing

the resident, initiating the care plan, and completing required assessment instruments, including the MDS.

Steps in the Procedure indicated the following: 7. Conduct an admission assessment (history and physical), including: (b) Relevant medical, social, and family history; (c) A list of active medical diagnoses and patient problems (such as recurrent falling or impaired mobility), especially those most related to reasons for admission to the facility and those that are affecting function, behavior, cognition, nutrition, hydration, quality of life, likelihood of functional recovery, and ability to participate in activities and to socialize.8.

Conduct a physical assessment, including the following systems: (a) Eyes, Ears, Nose, Throat; (j) Skin.9.

Conduct supplemental assessments (following facility forms and protocol) including: (b) Pain assessment; (f) Functional assessment - ability to perform ADLs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 Level of Harm - Minimal harm or potential for actual harm

assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating, oral hygiene, toileting hygiene, shower/bathe self, and upper body dressing.

During a review of Resident 9's CICE, dated 7/11/2025, the CICE indicated Resident 9 had an unwitnessed fall on 7/11/2025 and the staff notified the physician on 7/11/2025 at 10:15 AM.

Residents Affected - Some

During a review of Resident 9's CICE, dated 8/25/2025, the CICE indicated Resident 9 had a witnessed fall

on 8/25/2025 and the staff notified the physician on 8/25/2025 at 7 AM.

During a concurrent interview and record review on 9/3/2025 at 11:35 AM with Registered Nurse (RN) 2, Resident 6's Multidisciplinary Care Conference (also known as IDT), dated July, August, and September 2025, were reviewed. RN 2 confirmed that there was no IDT for Resident 6's two falls in July 2025.

During the same interview and record review on 9/3/2025 at 11:35 AM with RN 2, Resident 9's IDT, dated July, August, and September 2025 were reviewed. RN 2 confirmed that there was no IDT for Resident 9's two falls in July 2025 and one fall on 8/25/2025. RN 2 stated the facility should conduct an IDT for resident's post fall on the following day.

During an interview on 9/4/2025 at 3:46 PM with the Director of Nursing (DON), the DON stated the facility should have a post fall IDT meeting for all residents who experienced a fall.

During a review of the facility's Policy and Procedure (P&P) titled, “Safety and Supervision of Residents,” revised July 2017, the P&P indicated, “The interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risks for individual residents.”

During a review of the facility's P&P titled, “Falls Clinical Protocol,” revised March 2018, the P&P indicated, “For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Often multiple factors contribute to a falling problem.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0755

medication and before administering the next ones.”

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure the doorknob and door of residents' room for three of three sampled residents (Residents 11, 16, and 17) was cleaned daily. This failure had the potential for residents to become sick by contacting germs (microscopic bacteria, viruses, fungi, and protozoa that can cause disease) from the dirty doorknob.Findings:During a review of the facility's, Midnight Census Report (Census), dated 8/29/2025. The Census indicated Residents 11, 16, and 17 resided in Room (RM) A. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted Resident 11 on 3/13/2025 and readmitted Resident 11 on 5/16/2025 with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood).During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 6/18/2025, the MDS indicated Resident 11 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 11 required supervision (oversight, encouragement or cuing) from staff for bathing, dressing, and oral, toileting, and personal hygiene. During a review of Resident 16's AR, the AR indicated the facility admitted Resident 16 on 4/28/2025 and readmitted Resident 16 on 5/13/2025 with diagnoses including pneumonia (infection that inflames air sacs in one or both lungs), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).During a review of Resident 16's MDS, dated [DATE REDACTED], the MDS indicated Resident 16 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 16 required partial to moderate (helper does less than half the effort) assistance from staff for bathing, lower body dressing, and toileting and personal hygiene. During a review of Resident 17's AR, the AR indicated the facility admitted Resident 16 on 1/29/2025 and readmitted Resident 17 on 7/9/2025 with diagnoses including hypertensive (high blood pressure) heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body) and paranoid (where a person feels distrustful and suspicious of other people) schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).During a review of Resident 17's MDS, dated [DATE REDACTED], the MDS indicated Resident 17 had no impairment in cognitive skills (ability to make daily decisions). The MDS indicated Resident 17 required supervision (oversight, encouragement or cuing) from staff for eating, bathing, dressing, and oral, toileting, and personal hygiene.

During an observation on 8/29/2025 at 12:58 PM, Room A's door was observed. [NAME] specks and smudges were noted to be on the doorknob and on the door surrounding the doorknob. During a concurrent observation and interview on 9/2/2025 at 3:37 PM with the infection Preventionist (IP) Room A's door was observed. The door and doorknob were noted to still have brown specks and smudges first observed on 8/29/2025. The IP confirmed the door and doorknob were dirty. The IP stated the doorknob was a high touch area and should be cleaned daily to prevent the spread of infection.During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, the P&P indicated, .Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet