Glendora Grand, Inc. in Glendora: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

The 2567 report states that Resident 1 had intellectual disabilities, could not make decisions, and had severely impaired cognitive skills. An interdisciplinary team meeting in May 2023 called for Resident 1 to receive one-on-one supervision (one staff member watching one resident) to prevent falls. Inspectors found the facility failed to provide that supervision.

According to the report, on June 16, 2025, at about 5:35 p.m., Activity Assistant 1 left Resident 1 unsupervised in a wheelchair inside the resident's room. Activity Assistant 1 told inspectors that a nurse had given instructions to watch Resident 1 while also supervising other residents on the smoking patio, that Resident 1 wheeled back to the room and closed the door, and that about 30 seconds later the assistant found Resident 1 on the floor bleeding. Inspectors found Resident 1 had a cut on the left eyebrow measuring 2 by 1 by 0.5 centimeters, an abrasion (scrape) on the left elbow, and several abrasions on the left forearm. Paramedics took Resident 1 to a hospital, where the cut was closed with Steri-Strips (adhesive bandages).

The report states a licensed vocational nurse told inspectors Resident 1 was impulsive and would hit their head against objects when upset, and a registered nurse said it was not safe to leave Resident 1 alone. When inspectors observed Resident 1 nine days later, a staff member was providing one-on-one supervision, and the resident had a scab over the left eyebrow and a bruise under the left eye. The survey cited F689, accident hazards, supervision and assistive devices, at severity G, meaning actual harm.

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According to the citation, Resident 1 was a 47-year-old man who was assessed as at risk for elopement (leaving the facility without staff knowing) because of a history of elopement and wandering. He was first placed in a secured unit and moved the same day to an open unit. CDPH determined the facility failed to carry out his care plans, which called for safety precautions at all times, redirecting his behavior, and frequent visual checks.

The citation states a nurse saw him walk past the nurses' station at 7:45 p.m. on February 19, 2025, and a CNA saw him in the unit at 8:04 p.m. At 8:45 p.m. he could not be found. Staff searched the building, the grounds and nearby parks, stores and gas stations and called hospitals. CDPH found he was located on March 8, 2025, and readmitted on March 17. The department issued a Class A citation for patient care with a $20,000 penalty.

The federal 2567 report from the same investigation cited F687, foot care, at severity G, meaning actual harm, for a different resident, Resident 4, who had Parkinson's disease and dementia. Inspectors found licensed nurses did not notify Resident 4's physician or family when Resident 4 repeatedly refused podiatry treatment during 2024 and did not report the condition of the resident's thick, fungus-infected toenails. According to the report, Resident 4 was admitted to a hospital in February 2025 for intravenous antibiotics to treat osteomyelitis (a bone infection) in the right toes.

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The 2567 report states that Resident 1 had mild intellectual disabilities and walking problems, had moderately impaired cognition, and could not make medical decisions. A weekly nursing assessment on March 19, 2025, recorded Resident 1's skin as intact. Inspectors found the facility failed to make sure LVN 1 and RN 1 checked the resident's body on March 20 and 21 to prevent a wound from bracelets that had become embedded in the skin.

According to the report, LVN 1 noticed a foul smell from Resident 1 on March 20 but did not check other areas of the resident's body or tell a supervisor. On March 21, LVN 1 told RN 1 about the smell, and RN 1 told LVN 1 to give Resident 1 a shower. When emergency medical technicians came that day, they found swelling in the left arm and a hospital bracelet and personal beaded bracelets cutting into the skin of the left wrist, with signs and smell of infection and drainage. The bracelets were cut off, and a hospital emergency department noted an infected embedded band in the left wrist.

The director of nursing told inspectors the facility's skin assessment policy called for licensed nurses to do full-body skin checks as needed, and that LVN 1 and RN 1 did not check Resident 1's skin as the policy required. The report states these failures resulted in an infected wound on the left wrist. The survey cited F684, quality of care, at severity G, meaning actual harm.

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The 2567 report states that Resident 1, who had diabetes, lived in the facility's secured unit (a locked unit) after trying many times to wander out of the facility. The resident's care plan said Resident 1 was at risk for elopement and showed exit-seeking behavior. Inspectors found the facility failed to provide the supervision needed to prevent elopement.

According to the report, on August 13, 2024, at 7:07 a.m., Janitor 1 unlocked the secured unit's door and let Resident 1 leave with a rideshare driver for an 8 a.m. eye doctor appointment, with no staff chaperone or helper. Resident 1 never checked in at the doctor's office. Staff could not find the resident, and the facility filed a missing person report with local police at 11:17 a.m. The report states Resident 1 still had not been found as of August 16, 2024. Inspectors determined this put the resident at risk of serious harm from missing diabetes and other medications, lacking food and shelter, and hot weather.

The surveyor called an immediate jeopardy on August 15, 2024, in the presence of the administrator and the director of nursing, and removed it the next morning. According to the 2567 report, the facility's removal plan included one-on-one training for Janitor 1 and training for all staff not to unlock the secured unit without approval from the charge nurse or supervisor, a staff chaperone for every appointment, a new appointment log, and signs on every secured unit door. The survey cited F689, accident hazards and supervision, at severity J, the immediate jeopardy level.

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The 2567 report states the facility failed to provide care to prevent pressure ulcers (bed sores, damage to skin and tissue from constant pressure) and failed to treat existing ones for three sampled residents. Resident 228 had diabetes and end-stage kidney disease on dialysis, very limited mobility, and was assessed as at risk for pressure ulcers. Resident 228 was admitted with a small unstageable pressure ulcer (a wound covered by dead tissue, so its depth cannot be measured) on the left hip.

According to the report, inspectors found Treatment Nurse 1 and Treatment Nurse 3 did not give the wound care the physician ordered for open wounds on the right hip on four dates in July 2024, or for both hips on July 29. On July 24, a physician assistant found an unstageable pressure ulcer on the right hip measuring 5.5 by 5 centimeters and a worsened left hip ulcer measuring 7 by 4 centimeters. Inspectors found Treatment Nurse 3 did not notify the physician of the new ulcer and did not carry out the physician assistant's verbal order to clean and dress both hips. The report calls the right hip ulcer avoidable.

The inspectors also found Resident 231's low air loss mattress (a special mattress that helps protect the skin) was set for 325 pounds when the resident weighed 158 pounds, and that treatment nurses did not treat Resident 80's Stage 4 pressure ulcer (a deep wound that reaches muscle or bone) on the tailbone from July 25 to July 30, 2024. The survey cited F686, treatment and services to prevent and heal pressure ulcers, at severity G, meaning actual harm.

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According to the citation, Resident 1 was a 55-year-old man with Alzheimer's disease who had no teeth. His care plan said he was at risk for choking and called for staff to watch him during meals. His physician orders for life-sustaining treatment called for CPR and full treatment if his heart or breathing stopped.

CDPH determined that on April 19, 2024, at 6:20 p.m., CNA 1 set his dinner tray in front of him and left the room to get a towel. When CNA 1 returned at 6:22 p.m., Resident 1 had both hands at his mouth and was coughing, with ground meat on his hands. Staff gave the Heimlich maneuver, and a licensed vocational nurse found him unresponsive and removed food from his mouth. The citation states the registered nurse supervisor, LVN 1 and three CNAs did not immediately start CPR after he became unresponsive. Paramedics found him without breathing or a pulse, began CPR at 6:37 p.m., and he was pronounced dead at 7:01 p.m.

The 2567 report states inspectors also found a second resident did not receive immediate CPR in March 2024 and was pronounced dead. An immediate jeopardy was called on April 24, 2024, and the facility's removal plan included CPR classes for all nurses and CNAs and monthly mock code drills. The department issued a Class AA citation for patient care with a $120,000 penalty. The federal survey cited F678 (CPR) at severity K, F689 (accident hazards and supervision) at severity J, and F600 (freedom from abuse and neglect) at severity D.

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According to the citation, Patient 271 was a 78-year-old man with dementia who had a partial hip replacement after a broken left thigh bone. When he was readmitted in December 2022, assessments found full functional range of motion (the normal movement of a joint) in both arms and both legs. After physical therapy, physicians ordered restorative nursing care for him, including help walking from two staff members, walking with a front-wheeled walker, and assisted range of motion exercises for both legs.

CDPH found during its June 2023 recertification survey that the facility failed to provide the two-person walking assistance ordered in February 2023, failed to provide walker-assisted walking ordered in March 2023, and failed to provide the leg exercises from May 3 to June 8, 2023. Inspectors found no restorative nursing record for his walker sessions in March 2023. The citation states staff also failed to report his loss of motion in both legs and his growing difficulty going from sitting to standing to the rehabilitation staff, as his care plan required. By March 2023, a physical therapy evaluation noted new decreased strength, mobility and ability to walk safely.

The department determined these failures led to a moderate loss of motion in his left hip and both knees and a minimal loss in his right hip, which left him unable to stand upright. CDPH issued a Class A citation for patient care with a $25,000 penalty. The federal 2567 report cited F688, which covers preventing a decrease in range of motion and mobility, at severity G, meaning actual harm.

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According to the citation, Patient 1 was a 68-year-old man readmitted on October 7, 2022, for care after an amputation, with a bone infection of the left foot and ankle and loss of the left big toe. His care plan noted a history of constipation and fecal impaction (hard stool stuck in the colon or rectum) and called for staff to give his bowel medications as ordered and watch for signs such as bloating and decreased bowel sounds. On October 10 his abdomen became more swollen, and an X-ray the next day showed ileus (the intestines not moving normally) and a large amount of stool in the colon and rectum.

CDPH determined the facility failed to give Dulcolax doses on October 7 and 9 as ordered, failed to start the new Dulcolax and docusate orders on October 11, failed to check his bowel sounds on October 10, 11 and 12, and failed to record the size or amount of his bowel movements every shift from October 7 to October 16. On October 15, after he had trouble swallowing, a nurse practitioner ordered him sent to a hospital to rule out a bowel obstruction. The citation states he stayed in the facility and was not evaluated at a hospital until about 22 hours later.

According to the citation, a CT scan at the hospital showed free air in the abdomen, likely from a perforated bowel. He was moved to a second hospital and died there on October 17, 2022, from septic shock (a severe body-wide infection) caused by a bowel perforation. CDPH issued a Class A citation for patient care with a $25,000 penalty.

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