Arbor Glen Care Center: Gastrostomy Tube Care Failure - CA
Federal inspectors completed their review of Arbor Glen Care Center, located at 1033 E. Arrow Highway, on March 20, 2025. The citation covered the facility's handling of gastrostomy tube care, and inspectors classified the level of harm as minimal harm or potential for actual harm, with few residents affected.
A gastrostomy tube is surgically placed directly into a resident's stomach through the abdominal wall. Residents who rely on one typically cannot swallow safely or cannot consume enough food by mouth to sustain themselves. The tube is their nutrition. It is also a wound site, a point of entry into the body that requires consistent, careful attention to keep clean and functional. When that attention lapses, the consequences can move quickly from manageable to serious.
The inspection report does not describe the specific nature of the care failures inspectors observed. What it states is that the facility did not follow its own policy for providing proper care and maintenance of a gastrostomy tube.
That gap, between what a facility commits to on paper and what actually happens in a resident's room, is the one inspectors are trained to find.
Arbor Glen Care Center is a licensed skilled nursing facility. Residents who require gastrostomy tube feeding are, almost by definition, among the most medically fragile in any building. They may be recovering from a stroke, living with advanced neurological disease, or managing a condition that has made eating by mouth unsafe or impossible. Their care plans are specific. Their needs are not optional.
The citation was assigned a scope and severity level consistent with a deficiency that affected few residents and caused minimal harm or the potential for actual harm. That classification sits in the lower range of the federal deficiency scale, which runs from no actual harm with a potential for minimal harm at one end to immediate jeopardy at the other. A finding of minimal harm or potential for actual harm still means inspectors determined something went wrong, or came close enough to going wrong that it warranted a formal citation.
The facility's identification number with the Centers for Medicare and Medicaid Services is 056360.
For information on the nursing home's plan to correct the deficiency, CMS directs the public to contact the facility directly or reach out to the California state survey agency.
What the inspection record does not contain is a description of which resident or residents were affected, what specifically was observed at the bedside, or how long the lapse in care may have continued before inspectors arrived. Those details, when they exist in inspection reports, are what allow families to understand not just that something went wrong, but how it went wrong and whether it was an isolated moment or part of a longer pattern.
What the record does contain is a finding that a facility responsible for the care of medically vulnerable people did not follow its own standards for one of the most sensitive and consequential procedures in long-term care.
For any family member whose loved one depends on a gastrostomy tube for daily nutrition, that finding is not an abstraction. It is a question about what happened, and when, and whether anyone noticed before an inspector walked through the door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Glen Care Center from 2025-03-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 8, 2026 · Our methodology
ARBOR GLEN CARE CENTER in GLENDORA, CA was cited for violations during a health inspection on March 20, 2025.
Federal inspectors completed their review of Arbor Glen Care Center, located at 1033 E.
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.