Glendora Grand, Inc
GLENDORA GRAND, INC in GLENDORA, CA — inspection on April 10, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON), the facility P&P titled, Skin Assessment was reviewed.
The DON stated the policy indicated, it is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions, including pressure ulcers.
This P&P included the following procedural guidelines in performing the full body skin assessment.
Policy Explanation and Compliance Guidelines: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed.
The assessment may also be performed after a change of condition or after any newly identified pressure ulcer.
The DON stated the LN ' s did not follow the facility ' s policy.
The DON stated the facility has LVN ' s who perform weekly body checks and when LVN ' s notice anything unusual, LVN ' s are to report to RN ' s for further assessment of residents. DON stated RN 1 who was assigned to Resident 1 should have assessed further to find where the odor was coming from. DON stated the GACH transfer form filled out by RN 1 indicated swelling to left hand/arm but did not document anything else.
During a review of the facility's P&P titled, Comprehensive Care Plans, undated, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
056079 04/10/2025
Glendora Grand, Inc 805 W.
Arrow Hwy.
Glendora, CA 91740
During a concurrent interview and record review on 4/9/2025 at 2:20 p.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Skin Assessment, was reviewed.
The P&P indicated the procedural guidelines in performing the full body skin assessment.
The policy explanation and compliance guidelines indicated a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed.
The policy indicated the assessment may also be performed after a change of condition or after any newly identified pressure ulcer/ (localized damage to the skin and underlying tissue caused by sustained pressure) wound.
The DON stated the policy indicated, it is the facility ' s policy for staff (LVNs and RNs) to perform a full body skin assessment as part of our systematic approach for pressure ulcer/wound prevention and for the promotion of healing of various skin conditions.
The DON stated the LVN 1 and RN 1 did not assess/check Resident 1 ' s skin condition as indicated in the facility ' s policy.
During an interview and record review on 4/10/2025 at 3:00 p.m. with LVN 1, LVN 1 stated, LVN 1 was to assess Resident 1 further on 3/20/2025 when LVN 1 first noticed the smell coming from Resident 1 ' s body. LVN 1 stated when the EMS arrived at the facility on 3/21/2025, one of the members from the EMS (EMT 1) asked where the smell was coming from. LVN 1 stated EMT 1 was preparing to take Resident 1 ' s blood pressure when EMT 1 noticed Resident 1 ' s bracelets (on Resident 1 ' s left wrist). LVN 1 stated the beaded bracelets, and the hospital arm band (on Resident 1 ' s left wrist) were cut off and LVN 1 witnessed the items (the beaded bracelets and the hospital arm band) falling to the floor. LVN 1 stated LVN 1 did not see Resident 1 ' s wrist due to all the EMS staff huddling around Resident 1, but LVN 1 heard them (EMS staff) said, oh this is where the smell is coming from, and LVN 1 saw EMT 1 wrap Resident 1 ' s left arm with gauze. LVN 1 stated once the EMT 1 cut the bracelets off from Resident 1 ' s left wrist the smell got stronger, and it smelled like an infected wound.
056079 04/10/2025
Glendora Grand, Inc 805 W.
Arrow Hwy.
Glendora, CA 91740
During a review of the facility ' s P&P titled, Skin Assessment, undated, the P&P indicated, it is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions, including pressure ulcers.
This policy includes the following procedural guidelines in performing the full body skin assessment. A full body, or head to toes, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and as needed.
The assessment may also be performed after a change of condition or after any newly identified pressure ulcer.
During a review of the facility ' s P&P titled, Charge Nurse Job Description, undated, the P&P indicated, LNs provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures.
Required Qualifications, A Nursing Degree from an accredited college or university or a graduate of an approved LPN/LVN program., Current unrestricted license as a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) in practicing state.
Major Duties and Responsibilities Observes for changes in residents ' status, notifying the physician and resident ' s family or representative and documenting accordingly.
Reports any incidents or unusual occurrences to the supervisor, unit manager, assistant director or nursing or director of nursing and participates in the investigative process as needed.
During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 1/26/25, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired.
The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene, toileting hygiene, lower body dressing, and personal hygiene.
The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, and with putting on/taking off footwear.
The MDS indicated Resident 1 ' s did not have any skin conditions.
During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2025, the H&P indicated Resident 1 can make needs known but cannot make medical decisions.
During a review of Resident 1 ' s General Acute Care hospital (GACH) 1 ' s Emergency Department Provider Notes (EDPN), dated 3/21/2025, the EDPN indicated Skin: Rubber band embedded in the left wrist that appears infected.
During a review of GACH 1 History of Present Illness (HPI), dated 3/21/2025 at 1:04 p.m., the HPI indicated Resident 1 had an infection related to an embedded bracelet.
056079
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056079 B.
Wing 04/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Grand, Inc 805 W.
Arrow Hwy.
Glendora, CA 91740
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 1/26/25, the MDS indicated Resident 1's cognition was moderately impaired.
The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with showering/bathing, upper body dressing, The MDS indicated Resident 1 did not have any skin conditions.
During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2025, the H&P indicated Resident 1 was able to make needs known but could not make medical decisions.
During a review of Resident 1's Nursing Weekly Assessment (NWA), dated 3/19/2025, the NWA indicated Resident 1 ' s skin was intact.
During a review of Resident 1 ' s EMS run report (a standardized document used by emergency medical service care providers), dated 3/21/2025 and timed at 11:25 a.m., the report indicated, the emergency medical technicians (EMTs) arrived at the facility on 3/21/2025 at 11:30 a.m., and was at Resident 1 ' s bedside to evaluate Resident 1 at 11:31 a.m.
The EMS run report indicated, the EMTs noticed swelling to (left) arm, 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 (on the left wrist).
During a review of Resident 1 ' s GACH 1 ' s Emergency Department Provider Notes (EDPN), dated 3/21/2025, the EDPN indicated Skin: Rubber band embedded in the left wrist that appears infected.
During a review of GACH 1 History of Present Illness (HPI), dated 3/21/2025 at 1:04 p.m., the HPI indicated Resident 1 had an infection (on Resident 1 ' s left wrist) related to embedded bracelets.
056079
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056079 B.
Wing 04/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Glendora Grand, Inc 805 W.
Arrow Hwy.
Glendora, CA 91740
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.