Gladstone Sub-Acute: Trach Tube Incident Unreported - CA
The incident, which Resident 6 described to a respiratory therapist, involved certified nursing assistants who repositioned and changed the resident. The resident told the respiratory therapist that the tracheostomy tube came out during that process. Resident 6 also told a registered nurse that the tube had been accidentally disconnected once before, in a separate incident, though the resident could not remember when.
A tracheostomy tube is inserted through a surgical opening in the throat to maintain an airway. When it comes out unexpectedly, a condition called accidental decannulation, the risk of respiratory distress is immediate.
Nobody at Gladstone Sub-Acute wrote a care plan after the incident. Nobody documented a monitoring protocol for respiratory distress or vital signs. Nobody recorded what caused the tube to come out.
When inspectors interviewed the facility's own staff, the answers were consistent, and damning.
LVN 5 said a licensed nurse should have developed and implemented a care plan after the accidental decannulation. LVN 5 did not know the reason or details of what happened.
RN 2 said a care plan should have been developed to monitor for respiratory distress, track vital signs, and prevent the tube from coming out again. RN 2 also said RN 2 did not know the reason or details that caused the decannulation.
The Assistant Director of Nursing reviewed the resident's records with inspectors and confirmed that licensed nurses should have developed and implemented a care plan after the incident. The ADON said it was important to create one to prevent decannulation again and maintain the resident's well-being.
The Director of Nursing told inspectors the facility did not investigate the accidental decannulation and did not know its cause. The DON said it was important to investigate to find the cause and create a care plan to prevent it from happening again.
That acknowledgment came during the inspection. It had not come in the days or weeks before it.
The respiratory therapist who first learned about the incident from Resident 6 did not pass the information to the nursing staff responsible for updating the care plan. The registered nurse who learned the resident felt uncomfortable after the incident did not know an accidental decannulation had occurred that morning.
The facility's own policies required a licensed nurse to update the care plan when a resident has an accident, and to document each shift for at least 72 hours following a change in condition. None of that happened.
The CNAs who repositioned Resident 6 when the tube came out were never identified. No one at the facility, by the time inspectors arrived, had determined who was in the room, what they did, or what went wrong.
Resident 6, for their part, told a nurse the experience had been uncomfortable. That was the extent of the follow-up.
The inspection was filed as a complaint investigation. Inspectors rated the violation at a level of minimal harm or potential for actual harm, with some residents affected. That classification reflects the regulatory framework's assessment of documented risk, not a judgment that nothing serious occurred. A tracheostomy tube coming out of a resident's throat during care, with no investigation and no updated monitoring plan, is the kind of event that tends to look minor until it happens a second time.
At Gladstone Sub-Acute, as of this inspection, nobody knew enough about the first time to prevent a second.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gladstone Sub-acute and Rehab Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 20, 2026 · Our methodology
GLADSTONE SUB-ACUTE AND REHAB CENTER in GLENDORA, CA was cited for violations during a health inspection on May 28, 2026.
The incident, which Resident 6 described to a respiratory therapist, involved certified nursing assistants who repositioned and changed the resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.