Complaint Investigation

Arbor Glen Care Center

March 20, 2025 · Glendora, CA · 1033 E. Arrow Highway

Citations 5

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)

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 March 20, 2025.

Found 5 citations. 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

FF0693

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and

During a review of the facility ' s P&P titled, Gastrostomy Tube, dated 2/8/21, the P&P indicated it was part of the facility ' s Licensed Nurse Procedures.

The P&P indicated, it is the policy of this facility to provide proper care and maintenance of a gastrostomy tube .

056360 03/20/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

FF0726

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a

policy of this facility to provide proper care and maintenance of a gastrostomy tube .

056360 03/20/2025

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

FF0880

Provide and implement an infection prevention and control program.

During an interview on 3/20/25 at 10:16 am with the Director of Nursing (DON), the DON stated it was important for all staff to put on masks, gown, and gloves when providing care to residents on EBP to protect the residents from infection.

During a review of the facility ' s policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 1/2025, the P&P indicated, Enhanced Barrier Protection (EBP) is used in conjunction with standard precautions and expand use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization of MDROs) .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting .

FF693

Minimal harm or CNA 3 stated CNA 3 turned Resident 3's tube feeding machine to run after CNA 3 provided care to Resident Few During a subsequent interview on 3/20/25 at 5:29 am in Station 1 nurses' station with CNA 3, CNA 3 stated affected

During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.

The H&P also indicated Resident 3 had a gastrostomy tube.

During a review of Resident 3's Admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility.

The MDS indicated Resident 3 received tube feeding for nutrition.

During a review of Resident 3's physician's order (PO), dated 3/7/25, the PO indicated to provide [brand name] tube feeding via feeding pump machine (enteral feeding pump, a medical device used to deliver tube feeding directly to the stomach) to Resident 3 to run at 55 milliliters (ml, unit of measure) per hour to provide 1100 ml in 24 hours.

During an observation on 3/20/25 at 5:20 am inside Resident 3's room, Certified Nursing Assistant (CNA) 3 provided care to Resident 3 while Resident 3 was in bed. Resident 3's tube feeding machine at the bedside read, holding, which indicated Resident 3's tube feeding was on hold and not running or infusing.

During an observation on 3/20/25 from 5:23 am to 5:27 am outside Resident 3's room, no other staff went inside Resident 3's room while CNA 3 provided care to Resident 3 inside the room.

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 03/20/2025

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

Arbor Glen Care Center 1033 E.

Arrow Highway Glendora, CA 91740

FF726

Minimal harm or 1100 ml/1650 calories in 24 hours via feeding pump machine (enteral feeding pump, a medical device used Few During an observation on 3/20/25 at 5:20 am inside Resident 3 ' s room, Certified Nursing Assistant (CNA) 3 affected

During a review of Resident 3 ' s History and Physical (H&P, physician ' s clinical evaluation and examination of the resident), dated 3/3/25, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.

The H&P also indicated Resident 3 had a gastrostomy tube (G-tube, a tube surgically placed through the abdomen and into the stomach, and used to administer nutrition, liquids, or medications).

During a review of Resident 3 ' s Admission Minimum Data Set (MDS - a resident assessment tool), dated 3/4/25, the MDS indicated Resident 3 was dependent on others for oral hygiene, toileting hygiene, personal hygiene, upper and lower body dressing, putting on/taking off footwear, and with bed mobility.

The MDS indicated Resident 3 received tube feeding for nutrition.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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 03/20/2025

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.