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Complaint Investigation

Gladstone Sub-acute And Rehab Center

January 31, 2025 · Glendora, CA · 435 E. Gladstone St
Citations 2
CMS Rating 1/5
Beds 118
Provider ID 056118
Healthcare Facility
Gladstone Sub-acute And Rehab Center
Glendora, CA  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF684
Minimal harm or 1/16/2025 and Resident 1's Progress Notes, dated 1/16/2025 and 1/17/2025 were reviewed. The SBAR ray was ordered for Resident 1 on 1/16/2025 at 7:22 p.m. for increased congestion and affected

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

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 GLADSTONE SUB-ACUTE AND REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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