Gladstone Sub-acute And Rehab Center
GLADSTONE SUB-ACUTE AND REHAB CENTER in GLENDORA, CA — inspection on January 31, 2025.
Found 2 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
During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), end stage renal disease (ESRD, a condition in which a person's kidneys cease functioning), and required hemodialysis ( a process of filtering the blood of a person whose kidneys are not working normally).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills (ability to make daily decisions).
The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene.
The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and personal and oral hygiene.
A review of Resident 1's physicians orders (PO), dated 1/16/2025, timed at 7:19 pm, the PO indicated Resident 1 had an order for a STAT (immediately) chest X-ray due to increased congestion (an abnormal accumulation of fluid) and desaturation (a condition where oxygen levels in the blood drop).
During a telephone interview on 1/30/2025 with RP 1, RP 1 stated RP 1 visited Resident 1 at the facility on 1/16/2025. RP 1 stated while RP 1 was at the facility with Resident 1 on 1/16/2025 at around 5 p.m., Resident 1's O2 saturation (O2 saturation refers to the percentage of oxygen carried by red blood cells in the bloodstream) had dropped to 85% (normal range 95-100%). RP 1 stated the facility was going to order a chest X-ray because Resident 1's O2 saturation had dropped.
056118
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 056118 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Gladstone Sub-Acute and Rehab Center 435 E.
Gladstone St Glendora, CA 91740
During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 had diagnoses including congestive heart failure (CHF, the heart doesn't pump blood as well as it should), end stage renal disease (ESRD, a condition in which a person's kidneys cease functioning), and required hemodialysis ( a process of filtering the blood of a person whose kidneys are not working normally).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 10/24/2025, the MDS indicated Resident 1 was moderately impaired in cognitive skills.
The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene.
The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort) assistance from staff for dressing and personal and oral hygiene.
During a review of Resident 1's SBAR (Situation-Background-Assessment-Request) Communication Form (SBAR), dated 1/16/2025, timed at 11:06 pm., the SBAR indicated on 1/16/2025, untimed, Resident 1 had episodes of low oxygen, congestion (an abnormal accumulation of fluid), nausea and vomiting.
The SBAR indicated Resident 1 was noted with low oxygen (O2) saturation (O2 saturation- refers to the percentage of oxygen carried by red blood cells in the bloodstream) level of 85 percent (%) (normal O2 sat is 95% to 100%) on room air.
The SBAR indicated Resident 2 was placed on two (2) liters per minute (LPM) of oxygen via nasal cannula (NC- a thin, flexible tube that delivers oxygen through the nose) and still noted with 89% O2 sat.
The SBAR indicated oxygen was increased to four (4) LPM via NC and Resident 1's O2 saturation increased to 96%.
The SBAR indicated MD was made aware and ordered chest x-ray (CXR- a quick noninvasive imaging test that uses radiation to create pictures of the body) and Zofran (anti-nausea medication) as needed.
056118
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 056118 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Gladstone Sub-Acute and Rehab Center 435 E.
Gladstone St Glendora, CA 91740