Arbor Glen Care Center: Untrained Staff Risk Lives - CA
The March 20 incident at Arbor Glen Care Center exposed a dangerous pattern where untrained staff routinely operated medical devices beyond their scope of practice, while simultaneously ignoring infection control measures designed to protect residents from deadly complications.
Resident 3, who cannot understand or make decisions and depends entirely on others for basic care, receives nutrition through a gastrostomy tube surgically placed through the abdomen into the stomach. The resident's physician ordered tube feeding at 55 milliliters per hour, delivering 1,100 milliliters over 24 hours through a feeding pump machine.
At 5:20 that morning, inspectors observed Certified Nursing Assistant 3 providing care while the resident's feeding machine displayed "holding," indicating the life-sustaining nutrition had stopped flowing.
Seven minutes later, the machine read "running."
CNA 3 admitted she had restarted the feeding. "CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run after CNA 3 provided care to Resident 3," inspectors documented.
When confronted, the nursing assistant revealed her reasoning. She "stated CNA 3 turned Resident 3's tube feeding machine to run because CNA 3 did not want the tube feeding machine alarm to wake the residents up."
The admission exposed a facility where nursing assistants routinely manipulated complex medical equipment they were never trained to operate.
CNA 4 told inspectors it was "common practice" to put feeding machines on hold during care and restart them afterward. Yet both assistants acknowledged they weren't supposed to touch the equipment at all.
Licensed Vocational Nurse 5 explained the danger: "CNAs must not touch tube feeding machines because they could accidentally change the setting on the tube feeding machines."
Only licensed nurses are authorized to operate the devices, she said.
The Director of Staff Development confirmed nursing assistants receive no training on feeding tubes or pumps. "The DSD stated CNAs were not trained on how to operate tube feeding machines and operating tube feeding machines did not fall under the CNAs scope of practice."
During orientation and annual skills checks, nursing assistants are explicitly taught "not to disconnect any machines or equipment connected to residents and/or to turn machines or equipment connected to residents on or off."
A review of competency documents for both CNAs involved showed "feeding tubes and tube feeding machines were not included in the competency review and skills check."
The Director of Nursing called tube feeding "medication/treatment administration" that falls outside nursing assistant responsibilities entirely.
California law restricts nursing assistants to "basic patient care services directed at the safety, comfort, personal hygiene, and protection of patients" and prohibits "any services which may only be performed by a licensed person."
The facility's own gastrostomy tube policy, dated February 8, 2021, designates such care as part of "Licensed Nurse Procedures."
But the unauthorized medical interventions weren't the only safety violation that morning.
CNA 3 entered Resident 3's room without wearing the required isolation gown, despite a sign posted outside clearly indicating the resident was on Enhanced Barrier Precautions.
The infection control protocol requires gowns and gloves during high-contact care for residents with medical devices like feeding tubes, who face especially high risk of acquiring dangerous infections.
"CNA 3 stated staff must wear an isolation gown when providing care to Resident 3," inspectors noted. "CNA 3 stated CNA 3 forgot to put on an isolation gown when CNA 3 walked inside Resident 3's room."
The nursing assistant understood the requirement. She knew residents with gastrostomy tubes "were more at risk for infection." She simply forgot.
The Infection Prevention Nurse emphasized the stakes: staff must follow Enhanced Barrier Precautions "so that residents do not get infections." The Director of Nursing agreed the protocols were "important for all staff" to protect residents from infection.
The facility's January 2025 infection control policy explains that Enhanced Barrier Precautions prevent "indirect transfer" of dangerous organisms that can move from "resident-to-resident" through contaminated hands and clothing.
Residents with "wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization" of multidrug-resistant organisms, the policy states.
The protocol requires gowns and gloves during "high-contact resident care activities" including "dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting."
All activities CNA 3 would have performed that morning while improperly dressed.
Inspectors found the violations created potential for "actual harm" to residents. Untrained manipulation of feeding equipment could result in malnutrition, aspiration, or other complications for residents who depend entirely on tube feeding for survival.
The infection control failures could "spread infections to the residents, staff, and visitors that could lead to hospitalization and/or death."
Resident 3 represents the facility's most vulnerable population. Admitted with dysphagia and failure to thrive, unable to make decisions, completely dependent on staff for every aspect of care from oral hygiene to dressing to mobility.
The resident relies on properly functioning feeding equipment for basic nutrition and properly trained staff following infection protocols for protection from potentially deadly complications.
Instead, on March 20, Resident 3 received care from a nursing assistant who operated unauthorized medical equipment to avoid disturbing other patients and forgot basic infection control measures designed to prevent life-threatening infections.
The violations occurred during routine morning care, suggesting systemic problems with training, supervision, and adherence to safety protocols that protect the facility's most defenseless residents.
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: 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 20, 2026 · Our methodology
ARBOR GLEN CARE CENTER in GLENDORA, CA was cited for violations during a health inspection on March 20, 2025.
The resident's physician ordered tube feeding at 55 milliliters per hour, delivering 1,100 milliliters over 24 hours through a feeding pump machine.
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.