Arbor Glen Care Center: Scope of Practice Violation - CA
A March 2025 federal inspection of Arbor Glen Care Center, a nursing home at 1033 E. Arrow Highway in Glendora, found that certified nursing assistants were performing gastrostomy tube care on residents, a task California law explicitly reserves for licensed medical personnel. The violation affected a small number of residents and was cited at a level of minimal harm or potential for actual harm.
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See the Derila PillowA gastrostomy tube, commonly called a G-tube, is a feeding tube surgically placed through the abdominal wall directly into the stomach. Residents who depend on them are often among the most medically fragile in a facility, unable to swallow safely or take nutrition by mouth. Managing such a tube, including its care and maintenance, carries real clinical risk. Displacement, infection, and improper handling can cause serious injury.
Arbor Glen's own policy made the boundary clear. A procedure document titled "Gastrostomy Tube," dated February 8, 2021, listed the task under the facility's Licensed Nurse Procedures. The policy stated that it was the facility's practice to provide proper care and maintenance of a gastrostomy tube. The document did not leave room for interpretation about who was supposed to do it.
CNAs are not licensed. Under California Health and Safety Code, they are certified to provide basic patient care directed at safety, comfort, personal hygiene, and protection. The code is specific: those services cannot include anything that may only be performed by a licensed person. CNAs work under the supervision of a registered nurse or licensed vocational nurse, but supervision does not expand what they are legally permitted to do. The line between what a CNA can perform and what requires a license exists precisely because some tasks carry enough clinical complexity that the state has decided training and licensure matter.
At Arbor Glen, that line was crossed.
The inspection did not detail how many residents were affected beyond noting "few," and the report did not describe any specific injury or adverse outcome tied to the practice. The citation level of minimal harm or potential for actual harm reflects that inspectors found risk, not necessarily a documented injury in this instance. But the framing of a violation as "minimal harm" can obscure what it actually describes: unlicensed staff performing a clinical procedure on residents who had no way to know the person caring for their feeding tube was not authorized to do so.
What makes the finding harder to dismiss is the paper trail. This was not a case where a CNA improvised in an emergency or acted without any guidance. The facility had a written policy. That policy was labeled a licensed nurse procedure. Inspectors reviewing the document could see in plain language that Arbor Glen understood the task belonged to licensed staff. The gap between what the policy said and what staff were doing is the kind of gap that does not close on its own.
Arbor Glen Care Center is a skilled nursing facility operating under Medicare and Medicaid certification, which subjects it to federal inspection standards enforced through the Centers for Medicare and Medicaid Services. The March 20, 2025 inspection that produced this finding was a standard health survey.
The residents who received G-tube care from unlicensed aides during this period were not in a position to verify the credentials of the person performing the procedure. They were dependent, medically complex, and trusting that the facility had put the right person at the bedside.
The policy said it had. The inspection found otherwise.
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 12, 2026 · Our methodology
ARBOR GLEN CARE CENTER in GLENDORA, CA was cited for violations during a health inspection on March 20, 2025.
A March 2025 federal inspection of Arbor Glen Care Center, a nursing home 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.