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Complaint Investigation

Mesa Glen Care Center

November 21, 2025 · Glendora, CA · 638 E Colorado Avenue
Citations 2
CMS Rating 1/5
Beds 96
Provider ID 555854
Healthcare Facility
Mesa Glen Care Center
Glendora, CA  ·  View full profile →
Inspection Summary

Mesa Glen Care Center in GLENDORA, CA — inspection on November 21, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview on 11/21/2025 at 9:52 AM with the Director of Nursing (DON), the DON stated residents (in general) should not need to wait longer than 5 minutes for assistance in changing soiled briefs.

The DON stated this was necessary to maintain the residents' (in general) dignity.

During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

The P&P indicated, Demeaning -practices and standards of care that compromise dignity is prohibited.

Staff are expected to promote dignity and assist residents; for example. promptly responding to a resident's request for toileting assistance.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Glen Care Center

638 E Colorado Avenue Glendora, CA 91740

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/20/2025 at 12:23 PM with the Director of Nursing (DON), the DON stated a resident's (in general) healthcare provider who prescribed psychotropic medications was responsible for obtaining an informed consent for the psychotropic medications.

The DON confirmed an informed consent must be obtained for psychotropic medications when a resident (in general) was readmitted to the facility with orders psychotropic medications.

During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Informed Consent, undated, the P&P indicated, It is the policy of this facility to ensure that an informed consent is obtained for each resident's psychoactive medication .

The P&P indicated, If a resident was admitted with orders for psychoactive medication: a.

Verify that prior informed consent was obtained by discharging physician through a verified documentation was provided by discharging facility or hospital. b. If no documentation is present to verify informed consent has been obtained by discharging physician, the admitting physician will obtain informed consent for psychoactive medication from resident or resident's representative.

Facility ID:

Frequently Asked Questions

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.


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