Complaint Investigation

Arbor Glen Care Center

February 6, 2025 · Glendora, CA · 1033 E. Arrow Highway

Citations 1

CMS Rating 2/5

Beds 98

Provider ID 056360

Healthcare Facility

Arbor Glen Care Center

Glendora, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 11 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

ARBOR GLEN CARE CENTER in GLENDORA, CA — inspection on February 6, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF550

Minimal harm or 233's diaper. Resident 233 stated the Physical Therapist pressed the call light for Resident 233 to be Some Resident 233 stated Resident 233 did not always press the call light because Resident 233 was worried affected

During a review of Resident 233's Minimum Data Set (MDS - a resident assessment tool) dated 1/31/2025, the MDS indicated Resident 233 had intact cognition (ability to reason, think, plan) and required substantial or maximum assistance (helper does more than half the effort) for toileting hygiene and toilet transfers.

During an interview on 2/5/2025 at 11 AM with Resident 233's Family Member (FM), the FM stated the FM observed multiple times when Resident 233 had to wait 30 minutes to one hour for Resident 233's soiled brief to be changed.

During an interview on 2/6/2025 at 3:42 PM with the FM, the FM stated this morning around 9 AM, Resident 233 had soiled herself with feces and pressed Resident 233 the call light for assistance.

The FM stated Resident 233 was not changed until 11AM.

During an interview on 2/6/2025 at 4 PM with Certified Nursing Assistant (CNA) 4, CNA 4 stated the facility was short staffed at times especially during the evening and night shifts. CNA 4 stated the previous night on 2/5/2025 CNA 4 was assigned to care for eighteen residents which was difficult and unusual. CNA 4 stated the average amount of residents CNA 4 normally cared for was 10 to 11 residents which was manageable.

During a review of the facility's 11-7 AM CNA Assignment (CNAA), dated 2/5/2025, the CNAA indicated five CNAs were responsible for the care of 90 residents.

Four out of Five CNAs were assigned to care for 18 residents each.

056360

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056360 B.

Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLENDORA, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARBOR GLEN CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.