Health inspection·November 21, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lower body dressing, and personal hygiene. The MDS indicated Resident 6 was occasionally incontinent with bladder. During a review of Resident 6's untitled care plan, revised on 9/29/2025, the care plan indicated Resident 6 had an activity of daily living (ADL, a term used to describe the skills required to independently care for oneself) self-care performance deficit related to Parkinson's disease. The care plan indicated the interventions of, Encourage the resident to use bell to call for assistance, and The resident requires assistance by staff for toileting. During a telephone interview on 11/18/2025 at 8:58 AM with Resident 1's daughter (RR 1), RR 1 stated RR 1 usually visited Resident 1 at the facility in the evenings. RR 1 stated the facility staff (in general) took a long time to answer Resident 1's call light that RR 1 pushed for assistance. RR 1 stated RR1 would have to walk out to the nurses' station for assistance because the facility staff (in general) would not respond to Resident 1's call light. During an observation on 11/19/2025 at 9:22 AM, the light above Room A's door (a visual request for assistance) was observed to be on when the surveyor walked past the room. Certified Nursing Assistant (CNA) 1 later entered the room at 9:35 AM and spoke to Resident 4 who was lying in Resident 4's bed. The light above Room A's door was turned off at 9:35 AM. During an interview on 11/19/2025, at 9:35 AM with CNA 1, CNA 1 stated Resident 4 had pressed the call light to request assistance with changing Resident 4's soiled brief. During an interview on 11/19/2025, at 9:36 AM with Resident 4, Resident 4 stated Resident 4 had been waiting 30 minutes for someone to answer Resident 4's call light. Resident 4 stated Resident 4 had an incontinent episode and needed assistance to change his brief. Resident 4 stated Resident 4 sometimes had to wait up to 3 hours for assistance after pressing the call light. Resident 4 stated Resident 4 knew it took that long because Resident 4 kept track of the time with the clock hanging on the wall next to Resident 4's bed. Resident 4 stated the last time Resident 4 waited a long time for assistance with changing a soiled brief was an afternoon (cannot remember the date). Resident 4 stated it took 1 1/2 hour before a staff person answered the call light and another 1 1/2 hour to get changed from the soiled brief. Resident 4 stated that incident made Resident 4 feel irritated. Resident 4 stated Resident 4 felt ignored. Resident 4 stated Resident 4 felt Resident 4 was treated like a braindead invalid. During a follow-up interview on 11/19/2025, at 12:46 PM with CNA 1, CNA 1 stated residents (in general) should not have to wait long if the residents (in general) needed soiled briefs changed. During an observation on 11/19/2025 at 3:39 PM, the light above Room B's door was observed to be on when the surveyor walked past the room. CNA 2 later entered the room at 3:43 PM. The light above Room B's door was turned off at 3:43 PM. CNA 2 left the room at 3:43 PM (and did not return). During an interview on 11/19/2025 at 3:44 PM with Resident 6, Resident 6 stated Resident 6 pressed the call light because Resident 6 needed to be changed because Resident 6 had an episode of incontinence. Resident 6 stated Resident 6 had been waiting 30 minutes for assistance after pressing the call light. Resident 6 stated CNA 2 informed Resident 6 CNA 2 would be right back. During a concurrent observation and interview on 11/19/2025 at 4:03 PM with CNA 3, CNA 3 was observed entering Room B, speaking to Resident 6, and then exiting the room at 4:03 PM. CNA 3 returned to Room B at 4:05 PM and pulled privacy curtain around Resident 6's bed. CNA 3 stated CNA 3 was about to change Resident 6's diaper. CNA 3 stated Resident 6 had asked for assistance to change Resident 6's diaper when CNA 3 had checked on Resident 6 at 4:03 PM. CNA 3 denied that CNA 2 informed CNA 3 that Resident 6 needed assistance to change Resident 6's soiled briefs. During a follow-up interview on 11/21/2025 at 8:28 AM with Resident 6, Resident 6 stated that sometimes when Resident 6 pressed the call light, Resident 6 waited hours for someone to change Resident 6. Resident 6 stated the nighttime was the worst. Resident 6 stated Resident 6 urinated often and that sometimes Resident 6 yelled out for assistance. Resident 6 stated the yelling did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555854 If continuation sheet Page 2 of 5 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 11/21/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete help and that Resident 6 would just have to sit in my urine and pray they will come soon. Resident 6 stated when Resident 6 waited a long time for assistance, Resident 6 felt very frustrated. During an interview on 11/21/2025 at 9:52 AM with the Director of Nursing (DON), the DON stated residents (in general) should not need to wait longer than 5 minutes for assistance in changing soiled briefs. The DON stated this was necessary to maintain the residents' (in general) dignity. During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated, Demeaning -practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents; for example. promptly responding to a resident's request for toileting assistance. Event ID: Facility ID: 555854 If continuation sheet Page 3 of 5 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 11/21/2025 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained by the ordering healthcare provider for one of five sampled resident (Resident 1). This failure had the potential to result in Resident 1 receiving medication against Resident 1's wishes. (Cross Reference F550)Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2022 with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for eating, upper body dressing, and toileting, personal, and oral hygiene. The MDS indicated Resident 1 received psychotropic medications (affect brain activities associated with mental processes and behavior). During a review of Resident 1's Order Summary Report (OSR), dated 10/20/2025, The OSR indicated Resident 1 had the following medication orders upon Resident 1's readmission to the facility on [DATE]:Alprazolam Oral Tablet (Medication used to treat anxiety) 0.25 milligram (mg, a unit of measurement) Give 1 tablet by mouth at bedtime for Anxiety.Citalopram Hydrobromide oral tablet 10 mg (Medication used to treat depression) Give 1 tablet by mouth in the morning related to major depressive disorder.Mirtazapine oral tablet 15 mg (Medication used to treat depression) Give 1 tablet by mouth at bedtime for depression.Seroquel oral tablet 25 mg (medication used to treat schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly]) Give 0.5 tablet by mouth one time a day for schizophrenia. During a telephone interview on 11/18/2025 at 8:58 AM with Resident 1's daughter (RR 1), RR 1 stated Resident 1 took medications for Resident 1's dementia. RR 1 stated Resident 1's dementia medications were changed without notification being provided to RR 1. During a concurrent interview and record review on 11/20/2025 at 9:56 AM with the Social Service Director (SSD), Resident 1's Multidisciplinary Care Conference (MCC), dated 10/16/2025 was reviewed. The MCC indicated Resident 1 had been transferred to a General Acute Care Hospital (GACH) on 10/8/2025 and readmitted to the facility on [DATE]. The MCC indicated RR 1 had expressed concerns during the care conference meeting that Resident 1's depression medication dosage had been increased. The SSD stated the SSD was present during Resident 1's care conference meeting on 10/16/2025. The SSD stated RR 1's main concern was that RR 1 was not notified of the increased dosage of Resident 1's depression medication. The SSD stated the SSD was not sure if the medication dosages were changed while Resident 1 was at the facility or if the dosage was changed at the GACH and readmitted to the facility and continuing the new dosage. During a concurrent interview and record review on 11/20/2025 at 10:29 AM with the MDS Nurse (MDSN), Resident 1's MCC, dated 10/16/2025 was reviewed. The MDSN stated the MDSN was present during Resident 1's care conference on 10/16/2025. The MDSN stated the medication changes for RR 1 was concerned about happened when Resident 1 was at the GACH. The MDSN stated the facility continued the medication dosages Resident 1 received while at the GACH. During a concurrent telephone interview and record review on 11/20/2025 at 11:42 AM with Resident 1's Psychiatric Mental Health Nurse Practitioner (NP 1), Resident 1's four documents titled, Verification of Informed Consent to Psychotropic Drug, Physical Restraint or Medical Device (Informed Consent), all dated Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555854 If continuation sheet Page 4 of 5 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 11/21/2025 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 10/15/2025 were reviewed. The four Informed Consents were for the four psychotropic medications Alprazolam, Citalopram Hydrobromide, Mirtazapine, and Seroquel. The four Informed Consents incorrectly indicated NP 1 obtained informed consent from RR 1 for Resident 1 to receive the four psychotropic medications. NP 1 stated NP 1 did not obtain informed consent from RR 1 for the four psychotropic medications on 10/15/2025 when Resident 1 was readmitted to the facility. During an interview on 11/20/2025 at 12:23 PM with the Director of Nursing (DON), the DON stated a resident's (in general) healthcare provider who prescribed psychotropic medications was responsible for obtaining an informed consent for the psychotropic medications. The DON confirmed an informed consent must be obtained for psychotropic medications when a resident (in general) was readmitted to the facility with orders psychotropic medications. During a review of the facility's Policy and Procedure (P&P) titled, Psychoactive Medication Informed Consent, undated, the P&P indicated, It is the policy of this facility to ensure that an informed consent is obtained for each resident's psychoactive medication . The P&P indicated, If a resident was admitted with orders for psychoactive medication: a. Verify that prior informed consent was obtained by discharging physician through a verified documentation was provided by discharging facility or hospital. b. If no documentation is present to verify informed consent has been obtained by discharging physician, the admitting physician will obtain informed consent for psychoactive medication from resident or resident's representative. Event ID: Facility ID: 555854 If continuation sheet Page 5 of 5