Mesa Glen Care Center
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.
Inspection Findings
During a telephone interview on 1/29/2026 at 2:54 PM, RN 2 stated RN 2 was at the North Nursing Station charting on the computer while monitoring the unit. RN 2 stated Residents 3 and 4 were seated in their wheelchairs in the lobby area directly across from the nursing station. RN 2 stated RN 2 suddenly heard someone yelled, Ow, he hit me. RN 2 stated RN 2 immediately got up and responded, separating Residents 3 and 4. RN 2 stated RN 2 did not physically witness Resident 3 strike at Resident 4 but saw Resident 3 making a fist-like motion as if Resident 3 had punched Resident 4. RN 2 stated Resident 3 did not verbally admit to striking Resident 4. RN 2 stated Resident 3 had occasional verbal outbursts toward staff but had not previously witnessed physical aggression toward other residents. RN 2 stated that when a resident has a known history of aggressive behavior-whether directed toward staff or other residents, the care plan must be individualized, person-centered, and include specific, measurable interventions. RN 2 stated appropriate interventions should include clearly defined supervision levels, identification of behavioral triggers, early intervention strategies, structured de-escalation techniques, environmental modifications, redirection methods, staff approach guidelines, and criteria for escalation of care. RN 2 stated if the care plan had vague or generalized interventions and lacked behavior-specific guidance, staff would not have clear directions to proactively prevent escalation. RN 2 stated failure to implement clear, individualized interventions would contribute to resident-to-resident altercations and compromise resident safety.
During a concurrent interview with the Director of Nursing (DON) on 1/29/2026 at 3:33 PM and review of Resident 3's Care Plan Report, the DON stated following Resident 3's psychiatric hospitalization and subsequent readmission to the facility on 9/23/2025, the facility initiated a care plan addressing aggressive behavior.
The DON acknowledged that although a care plan to address Resident 3's aggressive behavior was implemented, the interventions were vague and not individualized or behavior specific.
The DON stated that when a resident has a known history of aggressive behavior, the care plan must be person-centered and include clear, specific, and measurable interventions.
The DON stated that the interventions should include identified triggers, defined supervision levels, early intervention strategies, structured de-escalation techniques, environmental modifications, staff approach guidelines, and clear escalation protocols.
The DON stated aggressive behaviors could remain dormant for extended periods but were unpredictable and could recur any time.
The DON stated, without detailed individualized interventions in place, staff lack clear direction to proactively prevent escalation, increasing the risk for resident-to-resident altercation, even if the aggressive behavior had remained dormant for several months and the resident had otherwise appeared stable.
During a review of the facility's P&P titled, Abuse Prevention/Prohibition, updated 7/2024, the P&P indicated: Abuse is defined as the willful inflictions of injury, involuntary seclusions, physical, or chemical restraint not required to treat the residents' symptoms, intimidation or punishment with resulting in physical harm, pain, or mental anguish.
Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.
Physical Abuse is defined as hitting, slapping, pinching, and or kicking. It also includes controlling behavior through corporal punishment.Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident's property.
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.
555854 01/29/2026
Mesa Glen Care Center 638 E Colorado Avenue Glendora, CA 91740
resident-specific guidance related to monitoring, identified triggers, and staff direction for managing
Resident 3's behaviors and increased the potential for resident-to-resident altercation, impacting
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.