Mesa Glen Care Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

December 2025, the progress notes indicated the Social Services Director (SSD) spoke with Resident 2 on 9/9/2025 and 9/10/2025 about Resident 2's room was a hazard to both Resident 2 and Resident 2's roommates. During a review of Resident 2's medical records with SSD, there were no other notes from October 2025 to November 2025 regarding assisting or encouraging Resident 2 to remove the clutter from Resident 2's room. During a review of Nursing Progress Notes, dated 12/22/2025, the progress note indicated Resident 2 refused for the room to be deep cleaned. Resident 2 was educated on proper cleaning and hygiene, but continued to refuse. During a review of Resident 2's Care Plan Report, titled Hoarding: Resident exhibits hoarding behavior as evidenced by overflow of belonging in a disorganized manner, the care plan's Goal section indicated the following goals: (1) Resident will be free of injuries related to clutter; and (2) Resident will maintain a safe and clean living area with assistance of the staff. The care plan report had initiation date of 7/31/2025 and target date of 3/22/2026. The care plan indicated the following interventions:Encouraged resident to place belongings in a secure place and assigned space area. (Date initiated: 8/10/2025. Revision on: 8/10/2025).Offer to clean and organize Resident 2's belongings (Date initiated: 7/31/2025; no revision date).Staff explain the risks and benefits of hoarding belongings and food. (Date initiated: 7/31/2025; no revision date).Staff will assist the resident with cleaning out any old and expired food products. (Date initiated: 7/31/2025, no revision date).Staff will monitor any new or increased behaviors associated with hoarding. (Date initiated: 7/31/2025, no revision date). During a review of Resident 2's Care Plan Report, titled Hoarding: Resident exhibits hoarding behavior as evidenced by overflow of belonging in a disorganized manner,, the care plan report did not indicate any reevaluation, revision, or date of update for the following interventions since the initiation date, after Resident 2 refused assistance and continued to have clutter in the room:Encouraging Resident 1 to place belongings in a secure place.Offer to clean and organize Resident 1's belongings.Staff will assist Resident 1 with cleaning out any old and expired food products.Staff will monitor any new or increased behaviors associated with hoarding. During a review of the facility's current Policy & Procedure (P&P), titled Care Plans, Comprehensive Person-Centered, with the revision date of December 2016, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P's Policy Interpretation and Implementation section indicated: Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The P&P further indicated, The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met.

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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

12/30/2025

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 Residents Affected - Few

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

belonging in a disorganized manner, the care plan's Goal section indicated the following goals: (1) Resident will be free of injuries related to clutter; and (2) Resident will maintain a safe and clean living area with assistance of the staff. The care plan had initiation date of 7/31/2025 and target date of 3/22/2026. The care plan indicated the following interventions:Encouraged resident to place belongings in a secure place and assigned space area. (Date initiated: 8/10/2025. Revision on: 8/10/2025).Offer to clean and organize Resident 2's belongings (Date initiated: 7/31/2025; no revision date).Staff explain the risks and benefits of hoarding belongings and food. (Date initiated: 7/31/2025; no revision date).Staff will assist the resident with cleaning out any old and expired food products. (Date initiated: 7/31/2025, no revision date).Staff will monitor any new or increased behaviors associated with hoarding. (Date initiated: 7/31/2025, no revision date). During a review of the facility's Policy & Procedure (P&P), titled Homelike Environment, with the revision date of February 2021, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible. The P&P's Policy Interpretation and Implementation section further indicated the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; inviting colors and decor.

During a review of the facility's Policy & Procedure (P&P), titled Infection Control: Standard Precautions, with the revision date of October 2018, the P&P indicated Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. The P&P's Policy Interpretation and Implementation section indicated: Environmental Control - Environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned.

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

12/30/2025

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to maintain a safe and sanitary ice and water handling practices to prevent contamination and the potential for waterborne illness for one of one ice machine serving the facility. This deficient practice had the potential to expose residents to unfiltered ice and water, which can harbor bacteria (Listeria, a bacterium), mold, and other contaminants, posing serious health risks and the potential for illness. During an observation on [DATE REDACTED] at 1:05 p.m. in the facility kitchen with the Dietary Manager (DM), an expired water filter, dated [DATE REDACTED], was observed connected to the icemaker. During an observation and concurrent interview with the Dietary Manager (DM) on [DATE REDACTED] at 1:14 p.m. in the kitchen, DM stated he was new and was unsure when the water filter needed to be changed for

the icemaker. Reviewed a log sheet on the side of the icemaker with DM. Observed the log was dated December, but no year was indicated. During an observation with the Dietary Manager (DM) on [DATE REDACTED] at 1:14 p.m. in the kitchen, a manufacturer's water filter specifications sheet was reviewed. The manufacturer's water filter specifications sheet indicated under Operations Tips: Replace cartridge when flow rate becomes inconveniently slow or before rated capacity is reached. It is recommended to replace cartridge at least once per year. During a review of the facility's current Policy & Procedure (P&P), titled Maintenance Service, with the revision date of [DATE REDACTED], the P&P indicated, Policy: Maintenance service shall be provided to all areas of the building, grounds and equipment. The P&P's Policy Interpretation and Implementation section further inidcated:The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Functions of maintenance personnel include but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards.The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.Maintenance personnel shall follow the manufacturer's recommended maintenance schedule.

Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

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Facility ID:

If continuation sheet