GLENDORA, CA - Federal investigators documented serious care deficiencies at Glendora Grand nursing facility during an August 2024 inspection, finding multiple instances where staff failed to provide required medical treatments and maintain safety protocols for vulnerable residents.
Pressure Ulcer Care Failures Lead to Worsening Conditions
The most severe violations involved failures in pressure ulcer prevention and treatment that resulted in residents developing avoidable wounds or experiencing deterioration of existing conditions.
Resident 228 exemplifies the consequences of inadequate wound care. This resident was admitted with diabetes, end-stage renal disease, and limited mobility - all factors that significantly increase pressure ulcer risk. While the resident entered the facility with one small unstageable pressure ulcer on the left hip, care breakdowns led to the development of a second pressure ulcer on the right hip and worsening of the original wound.
The right hip wound began as minor scratches in June 2024 but progressed to an unstageable pressure ulcer measuring 5.5 cm by 5 cm due to missed treatments. Records showed that staff missed wound care treatments on five separate days between July 6 and July 29, 2024. A physician's assistant assessment on July 24 found both hip wounds had deteriorated, but this critical information wasn't communicated to the medical team for three days due to documentation delays.
The facility's Director of Nursing acknowledged that "the right hip pressure ulcer could have been prevented by providing the wound treatment as ordered and implementing the care plan." Treatment records showed blank spaces where care should have been documented, indicating systematic failures in basic wound management protocols.
Medical Consequences of Inadequate Pressure Ulcer Care
Pressure ulcers develop when sustained pressure reduces blood flow to tissue areas, causing cell death and open wounds. For patients with diabetes and kidney disease like Resident 228, healing is significantly compromised due to poor circulation and reduced immune function. Missed treatments allow bacterial growth, increase infection risk, and can lead to life-threatening complications including sepsis.
Industry standards require pressure ulcer prevention through regular repositioning, specialized support surfaces, and immediate treatment of any skin breakdown. When ulcers do develop, consistent daily wound care with appropriate cleansing and dressing changes is essential to prevent deterioration.
Improper Medical Equipment Settings Create Safety Risks
Another serious finding involved improperly configured medical equipment that could have led to additional pressure ulcers. Resident 231, who weighed 158 pounds and was at high risk for skin breakdown, had a specialized pressure-relieving mattress set incorrectly at 325 pounds in static mode.
Licensed Vocational Nurse 1 identified the error during the inspection, explaining that "the current mattress setting was inaccurate for Resident 231 that could potentially cause pressure ulcers." The Director of Nursing confirmed that static mode provides maximum firmness and should only be used during care activities like transfers, not for continuous patient support.
Understanding Pressure-Relief Technology
Low air loss mattresses are sophisticated medical devices designed to prevent pressure ulcers by constantly adjusting air pressure based on the patient's weight and position. When set incorrectly, these mattresses fail to provide adequate pressure redistribution, essentially negating their protective benefits. For immobile residents like Resident 231, proper mattress function can mean the difference between healthy skin and painful, potentially dangerous wounds.
The facility's own policy required following manufacturer recommendations, but staff lacked proper oversight to ensure compliance with these critical safety protocols.
Treatment Gaps in COVID-19 Isolation Areas
Inspection findings revealed that residents in COVID-19 isolation areas experienced interrupted medical care. Resident 80, who had a Stage 4 pressure ulcer requiring daily wound care, missed six consecutive days of treatment while in the facility's "Red Zone" for COVID-positive residents.
Licensed nurses working in the isolation area stated they either didn't remember providing wound care or confirmed they missed treatments. One nurse explained she "did not sign the treatment record because she missed the wound care treatment." The Director of Nursing emphasized that "licensed staff needed to continue pressure ulcer treatment in the Red Zone," highlighting a breakdown in continuity of care protocols.
Medical Impact of Treatment Interruptions
Stage 4 pressure ulcers are the most severe category, involving full-thickness tissue loss extending to muscle, tendon, or bone. These wounds require daily specialized care to prevent infection and promote healing. Even brief interruptions in treatment can lead to rapid deterioration, increased pain, and potential life-threatening complications.
The COVID-19 pandemic created operational challenges for nursing homes, but regulatory standards still required facilities to maintain essential medical treatments for all residents regardless of isolation status.
Infection Control Protocol Violations
The inspection documented multiple infection control failures that could spread disease throughout the facility's 297 medically compromised residents. Staff were observed improperly handling contaminated materials and failing to follow isolation procedures.
In one instance, soiled gauze dressing was left on a resident's bed after wound care, creating contamination risk. More seriously, restorative nursing staff failed to properly remove isolation gowns and gloves when exiting a contact isolation room, potentially spreading infectious agents to other areas of the facility.
The facility's infection control policies clearly outlined proper procedures, but staff compliance was inconsistent. As one nurse explained, failure to follow protocols "could place the resident at risk for bacteria to enter" and cause widespread infection transmission.
Food Safety and Kitchen Sanitation Concerns
Dietary operations revealed systematic sanitation failures affecting food safety for all residents. Kitchen staff failed to follow manufacturer guidelines for testing sanitizer solutions, potentially serving food prepared with improperly sanitized equipment.
Multiple pieces of kitchen equipment showed concerning conditions including rusted storage racks, dirty ice machines with "slimy brownish buildup," and cracked serving trays with exposed metal. Staff were observed wearing prohibited jewelry during food preparation and storing dented cans with regular inventory.
The dietary manager acknowledged these conditions "could cause bacterial growth and lead to foodborne illness" in residents who are particularly vulnerable to infections due to their compromised health status.
Additional Issues Identified
Beyond the major violations, inspectors found numerous other deficiencies affecting resident care and safety:
- Speech therapy evaluations ordered by physicians were not completed for multiple residents - Psychotropic medications lacked required monitoring and dose reduction attempts - Respiratory equipment wasn't properly maintained according to manufacturer guidelines - Nursing staff information wasn't posted at all stations as required - Residents with dementia didn't receive appropriate behavioral interventions - Arbitration agreements were signed by residents without decision-making capacity - Hospice care documentation was incomplete and inaccurate
Industry Standards and Required Improvements
Federal nursing home regulations require facilities to provide comprehensive care that helps residents achieve their highest possible level of functioning while maintaining their safety and dignity. The violations at Glendora Grand represent failures across multiple essential care areas.
Proper pressure ulcer prevention requires systematic risk assessment, appropriate support surfaces, regular repositioning, and immediate intervention for any skin changes. When ulcers develop, evidence-based wound care protocols must be followed consistently to promote healing and prevent complications.
Infection control standards mandate strict adherence to isolation procedures, proper waste disposal, and thorough cleaning protocols to protect vulnerable residents from disease transmission. Food safety regulations require careful attention to equipment maintenance, sanitization procedures, and staff hygiene practices.
The comprehensive nature of these violations suggests systemic oversight failures rather than isolated incidents, indicating the need for substantial operational improvements to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendora Grand, Inc from 2024-08-02 including all violations, facility responses, and corrective action plans.
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