Mesa Glen Care Center

In the surveyor’s words

From the most serious findings on record at Mesa Glen Care Center, in the surveyor’s own words.

• Actual harm, patternF600Aug 2, 2024

  Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Residents 3 and 6) when on 7/24/24 Resident 2 hit/punched Resident 3's face and on 7/28/24 Resident 5 hit Resident 6 in the head with a water pitcher. These failures resulted in Resident 3 being subjected to physical abuse by Resident 2 and Resident 6 being subjected to physical abuse by Resident 5 while under the care of the facility. Resident 3 sustained facial fractures (break in bones on the face) and facial contusions (bruises) on Resident 3's right eye. […]

• Actual harm, isolatedF600Mar 25, 2025

  Based on observation, interview, and record review, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) failed to ensure one of five sampled residents (Resident 4) was not physically assaulted (attacked or harmed through physical violence) by another resident (Resident 5) on 3/20/2025. This deficient practice resulted in Resident 4 sustaining a closed head injury (type of traumatic brain injury where the skull remains intact) and mildly comminuted (bones break into pieces), minimally displaced (out of place) right nasal (nose) bone fracture (break in the bone) on 3/20/2025. Resident 4 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation of moderate head pain after a head injury from an assault. Findings: a. […]

• Actual harm, isolatedF689Mar 7, 2025

  Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent injuries for two of two sampled residents (Residents 37 and 294) by failing to: a. For Resident 37, the facility failed to: 1. Ensure Licensed Vocational Nurses (LVNs) implemented Resident 37's untitled Care Plan (CP), dated 2/26/2025, to provide interventions such as anticipating Resident 37's needs and providing opportunities for positive interaction/attention to Resident 37 to decrease or eliminate Resident 37's episodes of banging head on the walls/doors. 2. […]

• Actual harm, isolatedF580Mar 26, 2021

  Based on interview and record review, the facility failed to promptly (within approximately one-half hour or less) consult with Medical Doctor 1 (MD 1) and notify Responsible Party 1 (RP 1) for one of three sampled residents (Resident 1) as indicated in the facility's Clinical Protocol Acute Condition Changes policy when there was a significant change (a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions) in Resident 1's condition by failing to: 1. […]

• Actual harm, isolatedF684Mar 26, 2021

  Based on interview and record review, the facility's licensed nurses (Registered Nurse 1 [RN 1], Licensed Vocational Nurse 2 [LVN 2], LVN 3, and LVN 4), failed to identify signs and symptoms of stroke (lack of blood flow and oxygen in the brain due to blood clot or bleeding due to a tear in the blood vessels in the brain) and provide needed care and services to one of three sampled residents (Resident 1), as indicated in the facility's policy and procedure on stroke and Resident 1's stroke care plan. On [DATE] from 7 a.m. to 3:30 p.m., RN 1and LVN 2 observed Resident 1 was non-verbal, lethargic (tired and sleepy), difficult to wake up, and, not eating. At 5 p.m., LVN 3 and LVN 4 observed Resident 1 unresponsive with facial droop (a result due to the damage of the nerve in the brain). […]