Gladstone Sub-acute And Rehab Center
Inspection Findings
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
the H&P indicated Resident 4 had the mental capacity to make medical decisions. During a review of Resident 4's MDS, dated [DATE REDACTED], the MDS indicated the resident's cognitive skills for daily decisions making were intact. The MDS indicated Resident 4 was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing.
The MDS indicated the resident had both lower extremity impairment. During an interview on 9/16/2025 at 11 AM, Resident 4 stated he was frustrated about being unable to get out of bed when desired and had been spending more time in bed because staff could not always use the lift to transfer him to the specialized chair. d. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including Alzheimer's disease (progressive mental deterioration), and osteoarthritis (chronic breakdown of cartilage
in the joints leading to pain, stiffness, and swelling). During a review of Resident 5's H&P, dated 7/1/2025,
the H&P indicated Resident 5 could make needs known but could not make medical decisions. During a
review of Resident 5's MDS, dated [DATE REDACTED], the MDS indicated the residents' cognitive skills for daily decisions making were intact. The MDS indicated Resident 5 was dependent on nurses for toilet use and transfers, was not able to walk, and needed extensive assistance with bed mobility, personal hygiene, and dressing. During an interview on 9/16/2025 at 11:15 AM, Resident 5 stated she received more bed baths than she would like and preferred showers because showers made her feel cleaner. Resident 5 stated the lift was not always available to transfer her to the shower chair. During an interview on 9/16/2025 at 12:15 PM, CNA 1 stated that during the past week when only one Hoyer lift was operational across three nursing units, residents experienced delays in getting out of bed in the mornings and some residents had to receive bed baths instead of showers. CNA 1 stated, Residents still attend activities but arrive later than usual.
During an interview on 9/16/2025 at 12:30 PM, CNA 2 stated that residents who normally would be up earlier for showers and activities were being transferred later in the day. CNA 2 stated, We often have to give bed baths instead of showers because the lift isn't available. During an interview on 9/16/2025 at 12:50 PM, CNA 3 stated that with one lift available, multiple staff must wait their turn, which slowed morning care routines. CNA 3 stated, Residents are cared for but are getting up later and sometimes miss the start of activities. During an interview on 9/16/2025 at 1 PM, the Activities Director stated that residents continue to attend group activities; however, they have been arriving later than the scheduled start times. Activities usually begin around 7 AM, but in the past month residents have been arriving closer to 10-10:30 AM. The Activities Director attributed the delay to residents not being transferred out of bed on time. During an
interview on 9/16/2025 at 3 PM, the Maintenance Supervisor stated that for the past week the facility had one working Hoyer lift because the remote for the second lift was not functioning. He stated that a replacement remote was ordered and a new Hoyer lift had been received but could not be used for weighing residents until calibrated. The Maintenance Supervisor stated that once the new remote arrived,
the facility would have three operational Hoyer lifts. During a review of the facility's policy and procedure titled, Showering a Resident, dated November 1, 2017, the policy indicated, Residents are offered a shower at a minimum of once weekly and given per resident request.
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GLADSTONE SUB-ACUTE AND REHAB CENTER in GLENDORA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.