Glendora Grand: Resident Missing After Elopement - CA
Resident 1 was last seen walking around Station 6 at 8:04 pm on February 19. When staff checked his room at 8:45 pm, he was gone. Police were called at 10:05 pm after facility-wide searches failed to locate him.
The resident had been readmitted to Glendora Grand on February 7 from a general hospital. Two conflicting physician orders from that same day revealed the confusion that may have led to his disappearance. The first order specified admission to the secured unit due to wandering behavior. The second order indicated he could transfer to Station 6, an unsecured unit.
Staff followed the second order.
Licensed Vocational Nurse 4 told inspectors she saw the resident walking by the nurses' station at 7:45 pm on February 19. At 8:04 pm, Certified Nursing Assistant 14 spotted him walking in the hallway. Forty-one minutes later, CNA 14 couldn't find him in his room or bathroom.
The facility's emergency code for missing residents was activated. Staff searched every room and bathroom in the building, drove through neighboring areas checking parks, stores, gas stations and smoke shops, and called local hospitals. Nobody found him.
Director of Nursing told inspectors the resident was originally admitted to Station 3, another open unit, but had been found in the parking lot and moved to the secured unit by physician order. His discharge plan involved transfer to a board and care facility.
In December 2024, the resident's representative requested he be moved to an open unit to facilitate placement in assisted living or board and care. That's why he was placed in Station 6 when readmitted in February, the Director of Nursing explained.
The resident's care plan from September 2024 identified him as at risk for wandering due to impaired cognition, fluctuating mental status, anxiety disorder and schizophrenia. The plan called for staff to always alert colleagues to his whereabouts, distract him from facility doors, and place him in a secured unit if wandering continued.
An elopement risk evaluation completed February 7 confirmed he remained at high risk due to history of elopement and wandering behavior.
Station 6 had four exit doors. The main door in front of the nurses' station was neither alarmed nor locked. Three other doors — at the end of East Hall, West Hall, and by the kitchen — were alarmed but not locked. The kitchen door was not visible from the main hallway or nurses' station.
Licensed Vocational Nurse 1 told inspectors the resident "paced back and forth in the hallways" and frequently used the vending machine located by the kitchen exit door. No staff heard door alarms the night he disappeared.
The Maintenance Supervisor installed an alarm on the kitchen door February 20, the day after the elopement, on orders from the Administrator and Director of Nursing. "Back door by the kitchen where vending machines were could be where Resident 1 went out," the Director of Nursing told inspectors.
The resident required daily doses of buspirone for anxiety and olanzapine for schizophrenia. A February 10 physician evaluation noted he lacked capacity to understand and make decisions.
Federal inspectors found the facility violated regulations requiring adequate supervision to prevent accidents for residents at risk of elopement.
The same inspection revealed another serious medical failure involving a different resident who developed a bone infection after staff ignored a year of refused podiatry care.
Resident 4, who had Parkinson's disease and dementia, refused toenail treatment throughout 2024. Podiatry consultation notes from January 16, March 18, May 29, August 8, October 21, and December 26 all documented refusal of toenail debridement for nails described as "discolored, elongated, incurvated, dystrophic, hypertrophic, and painful with subungual debris."
On February 10, Certified Nursing Assistant 8 noticed the resident's toenails were "thick and long" during a shower, with the big toenail on the right foot "curving up." CNA 8 reported this to Licensed Vocational Nurse 9, who found the nails "long, thick, and dark yellowish green in color."
LVN 9 called the nurse practitioner, who ordered podiatry consultation and foot X-rays. The February 11 X-ray revealed "suspicious osteomyelitis on the right second distal phalanx and right fourth distal phalanx" — a bone infection.
The resident was transported to the hospital February 13 for treatment with intravenous antibiotics.
The Social Service Director told inspectors she was supposed to notify licensed nurses after any resident refused treatment three times, but admitted she "did not inform the licensed nurses when Resident 4 continued to refuse podiatry care for more than one year."
The Director of Nursing said she was "unaware Resident 4 had refused podiatry care for the whole year of 2024." She explained that nursing should have tried alternative interventions, notified physicians and family members, and conducted diagnostic studies.
LVN 9 acknowledged she should have completed a change-of-condition report February 10 when the nail problems were first reported, not three days later when X-ray results came back showing bone infection. "Long nails could cause residents discomfort and pain and put residents at risk for nails infections," she told inspectors.
The facility's policies required notification of physicians for treatment refusals and family notification for significant changes in residents' conditions. The Director of Nursing could not find documentation that the resident's family was informed of repeated podiatry refusals, and acknowledged licensed nurses "probably did not inform physicians" because they weren't aware of the ongoing refusals.
The resident's care plan identified risk for clinical decline due to refusal of activities of daily living, treatment and medications. It called for staff to monitor noncompliance episodes and refer for psychological or psychiatric consultation as ordered.
Federal inspectors cited the facility for failing to ensure residents receive necessary care and services to attain the highest practicable physical, mental and psychosocial well-being.
Both violations demonstrate systemic communication breakdowns at Glendora Grand that put vulnerable residents at serious risk. One resident remains missing. Another required emergency hospitalization for a preventable bone infection that developed over months of ignored warning signs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendora Grand, Inc from 2025-02-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
GLENDORA GRAND, INC in GLENDORA, CA was cited for violations during a health inspection on February 26, 2025.
Resident 1 was last seen walking around Station 6 at 8:04 pm on February 19.
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.
Frequently Asked Questions
- What happened at GLENDORA GRAND, INC?
- Resident 1 was last seen walking around Station 6 at 8:04 pm on February 19.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GLENDORA, CA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from GLENDORA GRAND, INC or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 056079.
- Has this facility had violations before?
- To check GLENDORA GRAND, INC's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.