Glendora Grand: Skin Assessment Failures After Hospital Transfer - CA
The April 2025 federal inspection report for Glendora Grand, a skilled nursing facility on West Arrow Highway, describes a sequence that the facility's own Director of Nursing later acknowledged should not have happened. A licensed vocational nurse, identified in the report as LVN 1, gave Resident 1 a shower on March 20, 2025. The next day, the smell was still there.
LVN 1 noticed the odor on March 21 and reported it to a registered nurse, identified as RN 1. The two went to the resident's room together. RN 1's response was to instruct LVN 1 to give the resident another shower.
LVN 1 told inspectors that LVN 1 had already informed RN 1 a shower had been given the day before and the smell had not gone away. RN 1 gave the same instruction anyway.
No full body skin assessment was completed. No one documented what might be causing the persistent odor. When Resident 1 was eventually transferred to an acute care hospital, RN 1 filled out the transfer form. It noted swelling to the left hand and arm. It documented nothing else.
The Director of Nursing reviewed the transfer form with inspectors during an interview on April 9, 2025. She said RN 1 should have assessed further to find where the odor was coming from. She said the licensed nurses did not follow the facility's own policy. She said the RN assigned to Resident 1 bore responsibility for the failure.
The facility's skin assessment policy, reviewed during that same interview, calls for a full head-to-toe skin assessment by a licensed or registered nurse upon admission, readmission, after a change in condition, or after any newly identified pressure ulcer. The Director of Nursing confirmed that standard was not met here.
She also described the facility's general approach: LVNs perform weekly body checks, and when they notice anything unusual, they are supposed to report to an RN for further assessment. That system, in this case, produced a report that went nowhere. LVN 1 reported the smell. RN 1 responded with a second shower order. The underlying cause, whatever it was, went unexamined.
The inspection report does not describe what was ultimately found at the hospital, what condition Resident 1 was in upon arrival, or what treatment followed. The transfer form, the last document the facility produced before the resident left, mentioned swelling in one limb and left everything else blank.
Inspectors cited the facility for failing to provide necessary care and services to maintain the highest practicable physical well-being of the resident. The level of harm was classified as minimal harm or potential for actual harm, and the citation noted that few residents were affected.
The Director of Nursing did not dispute the findings. She told inspectors directly that the nurses had not followed policy and that the assigned RN should have done more. What she did not explain, and what the inspection report does not resolve, is how a resident with a persistent unexplained odor and visible swelling to an arm could move through a two-nurse assessment and end up transferred to a hospital with a discharge form that captured almost nothing about what had been found.
Resident 1 left Glendora Grand on a form that noted swelling to the left hand and arm. What caused the smell that two showers could not fix was not recorded anywhere the inspectors could find.
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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Last verified: November 7, 2026 · Our methodology
GLENDORA GRAND, INC in GLENDORA, CA was cited for violations during a health inspection on April 10, 2025.
A licensed vocational nurse, identified in the report as LVN 1, gave Resident 1 a shower on March 20, 2025.
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.