Glendora Grand: Infected Wound Missed by Nurses - CA
Nobody checked the skin.
The resident, identified in inspection records only as Resident 1, had already been given a shower the day before, on March 20. The smell had not gone away after that shower either. The LVN noticed it then too, on March 20, and did nothing. No assessment. No escalation. The LVN later told inspectors that a full skin assessment was outside an LVN's scope of practice, and so the LVN did not check any area of Resident 1's body and did not notify a supervisor about the smell.
When the RN was finally told on March 21, the plan was another shower.
EMS arrived at the facility later that day. One of the emergency medical technicians, preparing to take Resident 1's blood pressure, noticed the smell and asked where it was coming from. The technician reached for Resident 1's left wrist to check vitals and noticed the bracelets, a set of beaded bracelets and a hospital armband, still on the wrist. The technician cut them off.
The LVN was in the room and watched the bracelets and armband fall to the floor. The EMS staff huddled around Resident 1, and the LVN could not see the wrist directly. But the LVN heard them say it: oh, this is where the smell is coming from. The smell got stronger the moment the bracelets were cut away. The EMT wrapped Resident 1's left arm in gauze. It smelled, the LVN told inspectors, like an infected wound.
Federal inspectors from the Centers for Medicare and Medicaid Services surveyed the facility on April 10, 2025, and cited the failure as causing actual harm to Resident 1.
The Director of Nursing, interviewed on April 9, walked inspectors through the facility's own written policy on skin assessments. The policy was clear: a full head-to-toe skin assessment is to be performed by a licensed or registered nurse upon admission or readmission, after any change in condition, and after any newly identified wound or pressure ulcer. The Director of Nursing acknowledged that neither the LVN nor the RN had followed it. "LVN 1 and RN 1 did not assess/check Resident 1's skin condition as indicated in the facility's policy," the Director of Nursing told inspectors.
The LVN, interviewed the following day, did not dispute any of it. The LVN acknowledged that a further assessment should have happened on March 20, when the smell was first noticed. The LVN said it was outside an LVN's scope of practice to assess the resident, but also acknowledged that the smell should have prompted escalation to the RN that same day, not the next morning.
What the inspection record does not say is how long the wound had been there, how it developed, or what treatment Resident 1 received after being taken by EMS. The report does not name Resident 1, does not describe the wound beyond the smell and the gauze wrapping, and does not say whether Resident 1 recovered.
What it does say is that for at least two days, a resident's wrist was rotting underneath a set of bracelets that no one thought to remove, while the people responsible for that resident's care ordered showers and moved on.
The bracelets came off in an emergency. The smell got stronger. And a stranger with a pair of scissors found what the nurses had not looked for.
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.
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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 30, 2026 · Our methodology
GLENDORA GRAND, INC in GLENDORA, CA was cited for violations during a health inspection on April 10, 2025.
The resident, identified in inspection records only as Resident 1, had already been given a shower the day before, on March 20.
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.