Glendora Grand: Infected Wrist Wound Missed - CA
The resident, who has mild intellectual disabilities and cannot make medical decisions, had been wearing the bracelets when staff noticed the odor on March 20. But no one investigated where the smell was coming from.
LVN 1 told inspectors she smelled something foul coming from the resident's body on March 20 but didn't check other areas of the body or notify her supervisor. "A full body assessment of a resident was not within LVN 1's scope of practice," she said.
The licensed vocational nurse gave the resident a shower that day. The smell remained.
The next morning, March 21, LVN 1 noticed the smell again and finally told RN 1 about it. The registered nurse instructed her to give the resident another shower. LVN 1 protested that she had already bathed the resident the day before and the smell hadn't gone away.
When EMTs arrived at 11:30 a.m. to transport the resident for an unrelated issue, they immediately noticed the swelling in the left arm. One EMT was preparing to take blood pressure when he discovered the source of the infection.
"Upon exposing arm, EMT noted a hospital bracelet and personal bracelets cutting into Resident 1's skin and showing signs and smell of infection with discharge coming from the wound," the EMS report stated.
The EMT cut off the beaded bracelets and hospital band, which fell to the floor. LVN 1 watched the EMTs huddle around the resident and heard them say, "Oh this is where the smell is coming from."
"Once the EMT cut the bracelets off from Resident 1's left wrist the smell got stronger, and it smelled like an infected wound," LVN 1 told inspectors.
Emergency department notes from the hospital described the injury as a "rubber band embedded in the left wrist that appears infected." The resident was diagnosed with an infection related to embedded bracelets.
The facility's own skin assessment policy required licensed nurses to perform full body examinations "upon admission/re-admission and as needed." The policy specifically stated assessments should be conducted "after a change of condition or after any newly identified pressure ulcer/wound."
Director of Nursing told inspectors the policy was designed as "a systematic approach for pressure ulcer/wound prevention and for the promotion of healing of various skin conditions."
Neither LVN 1 nor RN 1 followed the policy.
The resident had been living at Glendora Grand since 2015. A nursing assessment from March 19, just two days before the emergency, indicated the resident's skin was intact. The most recent comprehensive assessment in January showed the resident needed help with bathing and dressing but had no skin conditions.
LVN 1 later admitted to inspectors she should have assessed the resident further when she first noticed the smell on March 20. During the emergency response, she couldn't see the wound because EMS staff surrounded the resident, but she watched as the EMT wrapped the infected wrist with gauze.
The resident requires partial assistance with daily activities and can communicate needs but cannot make medical decisions due to cognitive impairment. The infection went undetected despite the resident being in the care of licensed nursing staff who were trained to identify and prevent exactly this type of wound.
Federal inspectors found the facility failed to ensure nurses had appropriate competencies to maximize resident wellbeing. The violation resulted in an untreated infected wound that required emergency medical intervention.
The resident had been wearing the bracelets and hospital band for an unknown period while staff conducted routine care, including showers, without noticing the jewelry was cutting into skin and causing infection.
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: 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 20, 2026 · Our methodology
GLENDORA GRAND, INC in GLENDORA, CA was cited for violations during a health inspection on April 10, 2025.
The resident, who has mild intellectual disabilities and cannot make medical decisions, had been wearing the bracelets when staff noticed the odor 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.