Glendora Grand: Wound Missed Until Hospital Transfer - CA
That transfer happened on March 21, 2025. The Director of Nursing told inspectors she had no idea the wound was there until that date.
Federal inspectors cited the facility following an April 10 inspection. The violation was tagged at the lower end of the harm scale, but the finding itself is direct: the nurses responsible for checking this resident's skin did not do it.
Glendora Grand's own policy requires licensed nurses to conduct full head-to-toe skin assessments, looking specifically for pressure ulcers and other skin conditions. The facility uses LVNs to perform weekly body checks. When an LVN spots something unusual, the policy calls for escalating to an RN for a fuller assessment. It is a straightforward two-step system.
Neither step happened for this resident.
The Director of Nursing confirmed to inspectors that LVN 1 and RN 1 had not assessed or checked the resident's skin condition as the facility's own policy required. She did not describe how long the wound had been present before the transfer. The inspection report does not say.
What the report does say is that the Director of Nursing learned about the wound the same day the resident left for the hospital. Not a day before. Not after a nurse flagged something during rounds. On the day of transfer.
The facility's charge nurse job description, which inspectors also reviewed, spells out what licensed nurses are supposed to do: observe for changes in residents' status, notify the physician and the resident's family, document accordingly, and report any unusual occurrences to supervisors. The document lists these as major duties. The LVN assigned to this resident's unit held a current license and was expected to meet those duties.
The skin assessment policy itself is undated, which inspectors noted. It does not carry a revision date or an implementation date. A policy without a date cannot be easily checked against when training occurred or whether staff had been recently reminded of its requirements. The inspection report does not say whether the facility was asked about that.
Pressure wounds can develop quickly in residents who are immobile or have circulation problems, and they can become serious before they are visible through clothing or bedding. Weekly skin checks exist precisely because wounds can be present without a resident reporting pain or discomfort. A resident who cannot communicate clearly, or who does not recognize that something is wrong, depends entirely on nursing staff to find problems before they worsen.
This resident depended on that system. The system did not work.
The Director of Nursing did not tell inspectors she had been unaware because the wound was hidden or because the resident had not shown signs of distress. She told them the LVN and the RN simply had not performed the assessments. That is the finding. Not a documentation gap, not a miscommunication between shifts. The checks were not done.
Glendora Grand is a licensed skilled nursing facility. The inspection covered a small number of residents in connection with this finding. The harm level was classified as minimal or potential for actual harm, the lower end of the federal scale, but that classification reflects the regulatory category, not the experience of a resident who arrived at a hospital with a wound their caregivers had never seen.
The Director of Nursing was aware of that wound for the first time on March 21. So, presumably, was the resident's family.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
GLENDORA GRAND, INC in GLENDORA, CA was cited for violations during a health inspection on April 10, 2025.
That transfer happened on March 21, 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.