Gladstone Sub-acute And Rehab Center
GLADSTONE SUB-ACUTE AND REHAB CENTER in GLENDORA, CA — inspection on May 28, 2026.
Found 1 citation. 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
PM with Resident 6, Resident 6 stated Resident 6's tracheostomy tube had been accidentally
with RNA 1, RNA 1 stated on the morning of [DATE] Resident 6 told RNA 1 Resident 6's tracheostomy
[DATE].During a phone interview on [DATE] at 4:35 PM with Respiratory Therapist (RT) 1, RT 1 stated Resident 6 had an accidental decannulation on [DATE]. RT 1 stated Resident 6 told RT 1 on [DATE] that Resident 6's tracheostomy came out after certified nursing assistants (CNAs) (unidentified) repositioned and changed Resident 6.During a phone interview on [DATE] at 2:14 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated licensed nurses should have developed and implemented a care plan after Resident 6 had an accidental decannulation. LVN 5 stated LVN 5 did not know the reason and the details regarding Resident 6's accidental decannulation on [DATE].During a phone interview on [DATE] at 4:25 PM with Registered Nurse (RN) 2, RN 2 stated RN 2 should have developed and implemented a care plan after Resident 6 had an accidental decannulation on [DATE] to provide care, to monitor for respiratory distress and vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature), and to prevent accidental decannulation again. RN 2 stated RN 2 did not know the reason or details that caused Resident 6's accidental decannulation on [DATE].During a concurrent interview and record review on [DATE] at 3:40 PM with the Assistant Director of Nursing (ADON), Resident 6's SBAR, dated [DATE], and current CPs were reviewed.
The ADON stated licensed nurses should have developed and implemented a CP regarding Resident 6's accidental decannulation on [DATE].
The ADON stated it was important to create a care plan regarding Resident 6's accidental decannulation to prevent decannulation again and to maintain the resident's well-being.
During an interview on [DATE] at 4:55 PM with the Director of Nursing (DON), the DON stated the facility did not investigate Resident 6's accidental decannulation on [DATE] and did not know the cause of the accidental decannulation.
The DON stated it was important to investigate the accidental decannulation to find the cause and create a care plan regarding resident's accidental decannulation to provide care to prevent decannulation again and maintain resident's well-being.During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, revised [DATE], the P&P indicated that the facility should ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.
The P&P indicated, A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed bases.During a review of the facility's P&P titled, Change of Condition Notification, dated [DATE], the P&P indicated when there is an accident involving a resident a licensed nurse must Update the Care Plan to reflect the resident's current status and A Licensed Nurse will document each shift for at least seventy-tow (72) hours.
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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.