GLENDORA, CA - State inspectors found that Glendora Grand nursing home failed to properly assess a resident with intellectual disabilities who developed a serious infection from an embedded rubber band bracelet on their wrist, leading to emergency hospitalization.
Delayed Discovery of Embedded Object Infection
The April 10, 2025 inspection revealed that a resident with mild intellectual disabilities and mobility issues lived with an infected embedded rubber band for an unknown period before staff discovered the problem. According to inspection records, the resident was ultimately transferred to a hospital emergency department on March 21, 2025, where medical providers documented "rubber band embedded in the left wrist that appears infected."
Hospital records noted the resident had "an infection related to an embedded bracelet," indicating the object had been in place long enough to cause tissue damage and bacterial invasion. For individuals with intellectual disabilities who may not effectively communicate discomfort, regular skin assessments become even more critical for early problem detection.
Staff Noticed Warning Signs But Failed to Investigate
The inspection found that Licensed Vocational Nurse 1 (LVN 1) detected a foul odor emanating from the resident's body on March 20, 2025, but failed to conduct a thorough assessment to locate the source. During interviews, LVN 1 admitted to not checking other areas of the resident's body or notifying supervisors about the concerning smell.
When the odor persisted after giving the resident a shower, LVN 1 waited until the following day to alert Registered Nurse 1 (RN 1). Even then, the nursing staff's response was limited to ordering another shower rather than conducting the comprehensive skin assessment required by facility policy.
Critical Breakdown in Assessment Protocols
The facility's own policies require licensed nurses to perform full-body skin assessments "upon admission/re-admission and as needed," including "after a change of condition." A persistent foul odor from a resident constitutes a clear change of condition that should have triggered immediate investigation.
Embedded objects can cause serious complications including cellulitis, abscess formation, and systemic infection. When foreign materials remain in tissue, bacteria can proliferate in the protective environment, leading to infections that may not respond to topical treatments. For residents with compromised immune systems or circulation issues, such infections can become life-threatening without prompt medical intervention.
The facility's Director of Nursing acknowledged that staff "did not assess/check Resident 1's skin condition as indicated in the facility's policy" and was unaware of the wound until the day of hospital transfer.
Scope of Practice Confusion Among Staff
The investigation revealed concerning gaps in staff understanding of their responsibilities. LVN 1 incorrectly stated that conducting full-body assessments was outside their scope of practice, despite facility policies clearly designating this as a required nursing function.
According to the facility's job descriptions, licensed nurses must "observe for changes in residents' status" and "report any incidents or unusual occurrences to the supervisor." The persistent odor clearly represented a status change requiring investigation and reporting.
This confusion about professional responsibilities can create dangerous gaps in resident care, particularly for vulnerable populations who may not advocate for themselves effectively.
Medical Consequences of Assessment Failures
Delayed recognition of embedded foreign objects can lead to several serious complications. Initially, the object may cause localized tissue irritation and pressure necrosis. As bacteria colonize the area, infection can spread to surrounding tissues, potentially causing cellulitis or deeper soft tissue infections.
In severe cases, untreated infections from embedded objects can progress to sepsis, requiring intensive medical intervention. The hospital transfer suggests this resident's condition had progressed beyond what could be managed at the nursing facility level.
For residents with intellectual disabilities, pain recognition and communication challenges make regular systematic assessments essential. These individuals may not understand or be able to articulate discomfort, making professional observation their primary protection against developing complications.
Additional Issues Identified
The inspection highlighted systematic problems with the facility's assessment protocols. Staff demonstrated inadequate understanding of their professional responsibilities, failed to follow established policies for skin monitoring, and showed poor communication between nursing staff levels.
The facility's weekly body check system, while present in policy, clearly failed to function effectively in practice. The gap between written procedures and actual implementation created vulnerabilities that allowed a preventable complication to progress to the point requiring emergency intervention.
This case underscores the critical importance of thorough, systematic assessment protocols, especially for residents with communication barriers who depend entirely on staff vigilance for health and safety monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendora Grand, Inc from 2025-04-10 including all violations, facility responses, and corrective action plans.
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