Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
4’23
41’24
60’25
41’26
146 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 26, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Aug 26, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| May 28, 2026 | D · potential | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Complaint |
| May 8, 2026 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| May 8, 2026 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| May 8, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| May 8, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| May 8, 2026 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| May 8, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 8, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| May 8, 2026 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| May 8, 2026 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| May 8, 2026 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| May 8, 2026 | E · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| May 8, 2026 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| May 8, 2026 | E · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| May 8, 2026 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| May 8, 2026 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| May 8, 2026 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| May 8, 2026 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| May 8, 2026 | E · potential | Post nurse staffing information every day. | Routine |
| May 8, 2026 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| May 8, 2026 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| May 8, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| May 8, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 8, 2026 | E · potential | Dispose of garbage and refuse properly. | Routine |
| May 8, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| May 8, 2026 | D · potential | Put firmly secured handrails on each side of hallways. | Routine |
| May 8, 2026 | D · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Apr 16, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 1, 2026 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Apr 1, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 1, 2026 | D · potential | Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Complaint |
| Apr 1, 2026 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 1, 2026 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Mar 16, 2026 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Feb 3, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Complaint |
| Feb 3, 2026 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 29, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 29, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 5, 2026 | E · potential | Post nurse staffing information every day. | Complaint |
| Dec 30, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 30, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 30, 2025 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Dec 11, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 1, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Nov 21, 2025 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Nov 21, 2025 | E · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Complaint |
| Sep 10, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 10, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Sep 5, 2025 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Sep 5, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Sep 5, 2025 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| Sep 5, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Sep 5, 2025 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Sep 5, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Sep 5, 2025 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 13, 2025 | D · potential | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Complaint |
| Jul 25, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jul 25, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 25, 2025 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Jul 2, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 23, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 5, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| May 22, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 15, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Apr 15, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 15, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 15, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Mar 25, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 7, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Mar 7, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Mar 7, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Mar 7, 2025 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Mar 7, 2025 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Mar 7, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Mar 7, 2025 | D · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Mar 7, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Mar 7, 2025 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Mar 7, 2025 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Mar 7, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Mar 7, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Mar 7, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Mar 7, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Mar 7, 2025 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Mar 7, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Mar 7, 2025 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Mar 7, 2025 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Mar 7, 2025 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Mar 7, 2025 | B · minimal | Post nurse staffing information every day. | Routine |
| Mar 7, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Mar 7, 2025 | E · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Mar 7, 2025 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Mar 7, 2025 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Mar 7, 2025 | E · potential | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Routine |
| Mar 7, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 7, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jan 23, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 7, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 7, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 7, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Dec 11, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 3, 2024 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Dec 3, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Nov 26, 2024 | D · potential | Prepare residents for a safe transfer or discharge from the nursing home. | Complaint |
| Nov 26, 2024 | D · potential | Plan the resident's discharge to meet the resident's goals and needs. | Complaint |
| Nov 20, 2024 | D · potential | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Complaint |
| Nov 20, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Nov 20, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Nov 20, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Nov 20, 2024 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Aug 9, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Aug 9, 2024 | D · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Complaint |
| Aug 2, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Aug 2, 2024 | H · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 18, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 26, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Apr 26, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 26, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 11, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 23, 2024 | E · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| Mar 22, 2024 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Mar 22, 2024 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Mar 5, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Mar 5, 2024 | E · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Mar 5, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Mar 5, 2024 | E · potential | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Routine |
| Mar 5, 2024 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Mar 5, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Mar 5, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Mar 5, 2024 | E · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Mar 5, 2024 | E · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Mar 5, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Mar 5, 2024 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Mar 5, 2024 | E · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Mar 5, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Mar 5, 2024 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Mar 5, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Mar 5, 2024 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Mar 5, 2024 | D · potential | Post nurse staffing information every day. | Routine |
| Mar 5, 2024 | E · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Mar 5, 2024 | E · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Oct 8, 2023 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Oct 8, 2023 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 8, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 8, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Mesa Glen Care Center
638 E Colorado Avenue, Glendora, CA 91740 · (626) 963-6091
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555854
- Certified beds
- 96
- Legal owner
- Mesa Glen Holdings LLC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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