Health inspection·September 10, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete anger at times, but those behaviors fluctuated. LVN 1 stated Resident 1's aggressive behavior was handled by staff by attempting to respond to the needs of the resident, using prescribed medications, or by talking with Resident 1 and if none worked, staff would give Resident 1 time alone and return at a later time. LVN 1 stated Resident 1 was only aggressive verbally and was not a physical threat. During an interview on 9/9/25 at 3:31 p.m. and review of a text message sent to RN 2, from RN 1, RN 2 stated the text message was dated 9/8/2025 at 10:53 p.m. RN 2 stated RN 2 did not see the text message from RN 1 until 9/9/2025 while driving to work. RN 2 stated RN 2 contacted the Administrator (ADM) and reported the text message from RN 1. The text message read as follows, I actually got mad when Resident 1 threw juice to my face that I went back to the cart to pour more juice and threw it back at Resident 1. During an interview with Certified Nursing Assistant 2 (CNA 2) on 9/9/2025 at 4:31 p.m., CNA 2 stated Resident 1 was agitated in the morning of 9/2/2025 (unable to give exact time), threw Resident 1's medication on the floor and threw juice on CNA 2 and RN 1. CNA 2 stated CNA 2 picked up the cup and returned it to RN 1, then RN 1 returned to the medication cart for another cup of juice, returned to Resident 1's room, and threw the juice in Resident 1's face and chest. Resident 1 was yelling and screaming profanities, then RN 1 left the room. During a phone interview with RN 1 on 9/9/2025 at 4:43 p.m., RN 1 stated Resident 1 saw RN 1 outside Resident 1's room and Resident 1 was cursing (using foul language), so RN 1 decided to give medications to another resident and returned to Resident 1 after. RN 1 stated, Resident 1 continued cursing as RN 1 gave Resident 1 juice to take with Resident 1's medications. RN 1 stated Resident 1 threw the juice at RN 1's face and on RN 1's clothes, then slapped the medications from RN1's hand. RN 1 stated, since the therapeutic medication was not working for Resident 1, RN 1 thought mirroring Resident 1's behavior would discourage Resident 1 from repeating the behavior. RN 1 stated RN 1 realized that throwing the cup of juice on Resident 1 was not allowed. RN 1 stated Resident 1 was neither harmed nor injured, since nothing heavy was thrown at the resident. During an interview with the Assistant [NAME] President for Operations (AVPOP) on 9/10/2025 at 11:30 am, the AVPOP stated what happened to Resident 1 was a horrible experience and RN 1 should not have thrown juice at Resident 1. The AVPOP stated Resident 1 should not have experienced abuse from RN 1. During an interview with the facility's ADM who was also the Abuse Coordinator (AC) on 9/10/2025 at 11:46 a.m., the AC stated staff were educated on different types of abuse including verbal, physical, neglect, financial, mental, sexual, seclusion, mistreatment, abandonment, and misappropriation of property. The AC stated all staff needed to report to the AC as soon as they became aware of any abuse. The AC stated the AC role was to investigate allegations of abuse and ensure an abuse free environment. During a review of the facility's undated Abuse Prevention/Prohibition Policy, (APP) the APP 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 physical harm, pain, or mental anguish. The APP policy also indicated that understanding behaviors and symptoms of residents that may increase the risk of abuse and neglect can assist staff how to respond; these symptoms, include but are not limited to aggressive and/or catastrophic reactions of residents, and outbursts or yelling out. During a review of the facility's Resident Rights Policy (RRP) dated 2/2021, the RRP indicated employees shall treat all residents with kindness, respect, and dignity. The RRP also indicated federal and state laws guarantee certain basic rights to all residents of the facility and these rights included the resident's right to: c) be free from abuse, neglect, misappropriation of property, and exploitation. Event ID: Facility ID: 555854 If continuation sheet Page 2 of 4 Printed: 05/15/2026 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 555854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of physical abuse for one of three sampled residents (Resident 1) within two hours to the California Department of Public Health in accordance with the facility's Policy and Procedure (P&P) titled, Abuse Reporting and Investigation.This failure violated Resident 1's right and had the potential for delay in abuse investigation and continued to expose Resident 1 to further physical abuse.Findings: During a record review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses including intellectual disability (term used to describe a person with certain limitations in cognition [process of acquiring knowledge] and other skills including communication and self-care), Schizoaffective Disorder Bipolar Type (a mental condition that causes both a loss of contact with reality and mood problems) and Unspecified Anxiety Disorder (excessive and persistent worry and fear that significantly interfere with daily life). During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/9/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 had a history of verbal behaviors of threatening, screaming, and/or cursing toward others. The MDS indicated Resident 1 had lower extremity (hip, knee, ankle, foot) impairment and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing, lower extremity dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 1's untitled Care Plan (CP) initiated on 3/4/2025, the CP indicated Resident 1 had the potential to be physically aggressive related to schizoaffective disorder, intellectual disabilities and poor impulse control. The CP interventions indicated for staff to provide physical and verbal cues to alleviate anxiety. During a review of Resident 1's untitled CP initiated on 3/4/2025, the CP indicated Resident 1 had impaired cognitive function related to developmentally delayed and schizoaffective disorder. The CP interventions indicated for staff to provide Resident 1 with necessary cues and to stop and return to Resident 1 if Resident 1 was agitated. During a review of Resident 1's untitled CP revised 4/6/2025, the CP indicated Resident 1 had a behavioral problem. The CP interventions indicated for staff to provide positive interaction and attention, stop and talk with Resident 1 when passing by Resident 1's room, explain all procedures to Resident 1 before starting, and allow Resident 1 to adjust to changes. During a review of Resident 1's untitled CP revised 4/9/2025, the CP indicated Resident 1 had behavioral symptoms as manifested by resistance to care. The CP interventions indicated approaching Resident 1 in a calm manner. During an interview with Registered Nurse 2 (RN2) on 9/9/2025 at 3:31 p.m., RN 2 stated staff were taught who to report any type of abuse within a two-hour timeframe. RN 2 stated staff needed to report any type of abuse to the Abuse Coordinator, immediately, within 2 hours of any physical, verbal, sexual, financial, neglect, exploitation, isolation, or mistreatment. In a concurrent review, RN 2 showed a photocopy of a text message from RN 1. RN 2 stated the text message was dated 9/8/2025 at 10:53 pm. The text message indicated: I actually got mad when he (Resident 1) threw the juice to my face that I went back to the cart to pour more juice and threw it back at him (Resident 1). RN 2 stated RN 2 did not see the text message from RN 1 until 9/9/2025 while driving to work. During an interview with Certified Nursing Assistant 2 (CNA 2) on 9/9/2025 at 4:31 p.m., CNA 2 stated Resident 1 was agitated in the morning of 9/2/2025 (unable to state exact time), threw Resident 1's medication on the floor and threw juice on CNA 2 and RN 1. CNA 2 stated CNA 2 picked up the cup and returned it to RN 1, then RN 1 returned to the medication cart for another cup of juice, returned to Resident 1's room, and threw the juice in Resident 1's face and chest. Resident 1 was yelling and screaming (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555854 If continuation sheet Page 3 of 4 Printed: 05/15/2026 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 555854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete profanities, then RN 1 left the room. CNA 2 stated all staff were mandated reporters. CNA 2 stated what happened between RN 1 and Resident 1 should have been reported to the Administrator (ADM), who was also the Abuse Coordinator, but CNA 2 became busy with CNA 2's assignment and failed to report the incident. CNA 2 stated any incident of abuse should be reported within 2 hours of the abuse. During an interview with the facility's Assistant [NAME] President of Operations (AVPOP) on 9/9/2025 at 2:56 p.m., the AVPOP stated the facility's Director of Nursing (DON) informed the AVPOP that a staff member (RN 2) received a text message from RN 1 indicating abuse. The AVPOP stated the text message from RN 1 indicated RN 1 got mad when Resident 1 threw juice at RN 1's face and so RN 1 went back to the medication cart to pour more juice and threw it back at Resident 1. The AVPOP stated staff (in general) needed to report abuse immediately. During a review of the facility's undated Abuse Prevention/Prohibition Policy (APP), the APP 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 resulting physical harm, pain, or mental anguish. The APP indicated physical abuse is defined as hitting, slapping, pinching, or kicking; it also includes controlling behavior through corporal punishment. During a review of the facility's undated Policy and Procedure (P&P) titled Abuse Reporting and Investigation, the P&P indicated allegations of abuse, neglect, mistreatment or exploitation are to be reported to the Abuse Prevention Coordinator immediately. The P&P indicated the facility will report all allegations of abuse, as required by law and regulations to the appropriate agencies within two hours. Event ID: Facility ID: 555854 If continuation sheet Page 4 of 4