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Complaint Investigation

Mesa Glen Care Center

January 29, 2026 · 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 January 29, 2026.

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

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

During a review of the facility's P&P titled, Resident Rights, updated 2/2021, the P&P indicated:Federal and state laws guarantee certain basic rights to all residents of this facility.

These rights include the resident's right to:Be free from abuse, neglect, misappropriation of property, and exploitation.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Mesa Glen Care Center

638 E Colorado Avenue Glendora, CA 91740

SUMMARY STATEMENT OF DEFICIENCIES

3:45 PM, Resident 3's Care Plan Report initiated on 9/26/2025 was reviewed with the Director of Nursing (DON).

The DON acknowledged the care plan addressed Resident 3's aggressive behavior but did not reflect a comprehensive, individualized, person-centered approach.

The DON stated the care plan was missing resident-specific guidance related to monitoring, identified triggers, and staff direction for managing aggressive behaviors.

The DON stated the documented interventions were not implemented in a timely manner until 11/5/2025, which limited the staff's ability to consistently prevent and manage Resident 3's behaviors and increased the potential for resident-to-resident altercation, impacting resident's safety.

During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised on 3/2022, the P&P indicated: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 interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.The Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including:The right to participate in the planning processParticipate in establishing the expected goals and outcomes of care, andParticipate in determining the type, amount, frequency, and duration of careThe comprehensive, person-centered care plan:Includes measurable objectives and timeframesDescribes the services that are to be furnished to attain or maintain the resident's physical, mental, and psychosocial well-being, includingThe resident's stated goals upon admission and desired outcomesReflects currently recognized standards of practice for problem areas and conditionsCare plan interventions are chosen only after 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.Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan:When the resident has been readmitted to the facility from a hospital stay.

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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