Inspection Report

Gladstone Sub-Acute Fails Dietary, Medication Safety CA

October 17, 2025

Glendora, CA

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GLENDORA, CA - Inspectors found that Gladstone Sub-Acute and Rehab Center repeatedly prepared meals with oil and grease for a diabetic resident who had his gallbladder removed, despite documented food restrictions and the resident's multiple requests for grease-free meals.

Weight Loss Linked to Dietary Issues

The June 2024 inspection revealed serious dietary management failures affecting a resident with type 2 diabetes and a history of gallbladder removal. The resident experienced a significant 12.6% weight loss over six months, dropping from 142.6 pounds in November 2023 to 125.4 pounds by May 2024, falling below the target weight range of 130-140 pounds.

The resident's medical condition required strict avoidance of fatty and greasy foods. Without a gallbladder - the organ responsible for breaking down fats - consuming oily foods triggered immediate digestive distress including diarrhea and abdominal pain. Despite these documented medical needs, kitchen staff continued preparing the resident's requested hamburgers using oil in regular pans rather than dry-cooking methods or using non-stick pans without oil.

During an interview with inspectors, the resident expressed frustration: "I eat as much as I could and if I lose weight, I lose weight," and later stated, "I'm tired of arguing, I just don't have the strength to argue anymore [and] I just eat what is given to me."

Medical Significance of Gallbladder-Related Dietary Restrictions

When the gallbladder is removed through cholecystectomy, the body loses its ability to store and concentrate bile, which is essential for fat digestion. Bile is produced continuously by the liver but without the gallbladder's storage function, consuming fatty foods can lead to bile acid malabsorption, resulting in chronic diarrhea, bloating, and abdominal cramping.

For individuals without gallbladders, dietary fat should typically be limited to 20-30% of total daily calories, with an emphasis on avoiding fried foods, high-fat meats, and foods cooked with oils. The digestive complications from consuming inappropriate foods can lead to malnutrition, dehydration, and significant weight loss - exactly what occurred in this case.

The resident's diabetes added another layer of complexity, as uncontrolled blood sugar combined with poor nutrition absorption creates heightened risks for complications including diabetic neuropathy, cardiovascular problems, and delayed wound healing.

Kitchen Staff Acknowledged Alternative Cooking Methods

The inspection revealed that dietary staff were aware of appropriate alternatives but failed to implement them consistently. The cook acknowledged preparing the resident's hamburger patties with oil in regular pans, while a clean, unused non-stick pan was observed nearby. The Dietary Services Supervisor stated there were "other ways to cook a hamburger patty such as grilling or steaming the patty" but continued using oil-based preparation methods.

When the resident specifically requested fried eggs cooked without oil on non-stick pans, the Dietary Services Supervisor claimed "oil was needed to cook eggs" and stated "I cannot cook eggs without oil." However, eggs can be successfully prepared on properly seasoned non-stick surfaces without added fats, especially when accommodating specific medical dietary restrictions.

The facility's food preference documentation system also proved inadequate. The resident's food preference ticket failed to specify the critical need for oil-free preparation methods, despite multiple documented requests dating back to June 2023. The Registered Dietitian was unable to provide documentation of specific food alternatives offered to address the resident's digestive limitations.

Breakdown in Care Coordination

The Assistant Director of Nursing acknowledged that the resident's food preferences were "ordinary, manageable, and could easily be provided by the facility" and stated that "food preferences were not followed [for Resident 40] by the kitchen [staff]." This admission highlighted a clear disconnect between the facility's policies and actual implementation.

The facility's own policies emphasized accommodating residents' individual needs and preferences "to the extent possible" and ensuring meals were "served according to expressed resident preferences." However, the care team's failure to properly communicate and implement medically necessary dietary modifications directly contributed to the resident's deteriorating nutritional status.

Monthly weight variance reviews documented the progressive weight loss but failed to adequately address the underlying dietary preparation issues. Despite identifying that the resident "wanted foods with little to no oil due to experiencing diarrhea," appropriate interventions were not consistently implemented.

Food Safety Violations Compound Concerns

Beyond the dietary accommodation failures, inspectors discovered additional food safety violations that raised concerns about the facility's overall food service management. Kitchen staff failed to properly rotate perishable items, leaving expired products in refrigerated storage.

Inspectors found 22 apples that had exceeded the facility's own one-month refrigerated storage guideline, along with an unopened gallon of whole milk that had passed its expiration date. The Dietary Services Supervisor acknowledged these items "could make residents sick" and should have been removed from storage immediately.

These violations indicate systemic issues with food safety protocols and inventory management, suggesting broader oversight problems within the dietary department.

Additional Issues Identified

The inspection also documented other regulatory violations including infection control deficiencies and medication management concerns, though these were classified as having minimal potential for harm compared to the dietary violations.

The facility maintained policies for managing unplanned weight loss and nutrition variance that defined weight loss greater than 10% over six months as "severe." However, implementation of these policies appeared inadequate given the documented 12.6% weight loss experienced by the affected resident.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Gladstone Sub-acute and Rehab Center from 2024-06-13 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 22, 2026 · Our methodology

Quick Answer

GLADSTONE SUB-ACUTE AND REHAB CENTER in GLENDORA, CA was cited for violations during a health inspection on June 13, 2024.

The resident's medical condition required strict avoidance of fatty and greasy foods.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at GLADSTONE SUB-ACUTE AND REHAB CENTER?

The resident's medical condition required strict avoidance of fatty and greasy foods.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GLENDORA, CA, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from GLADSTONE SUB-ACUTE AND REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 056118.

Has this facility had violations before?

To check GLADSTONE SUB-ACUTE AND REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.