Glendora Grand, Inc

In the surveyor’s words

From the most serious findings on record at Glendora Grand, Inc, in the surveyor’s own words.

• Immediate jeopardy, patternF678Apr 26, 2024

  Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to two of three sampled residents (Resident 1 and Resident 5) who had a full code status (when the resident's heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) by failing to ensure: 1. […]

• Immediate jeopardy, isolatedF689Aug 16, 2024

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent elopement (when an individual leaves the healthcare facility unsupervised and/or undetected) for one of five sampled residents (Resident 1) who was assessed as at risk for elopement as indicated in the facility's policy and procedure titled, Elopements and Wandering Residents, by failing to: 1. Ensure Janitor 1 ([DATE]) did not unlock the door of the facility's secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision) to allow Resident 1 to leave the facility without a staff chaperone (a person who goes with and looks after another person or… […]

• Immediate jeopardy, isolatedF689Apr 26, 2024

  Based on interview and record review, the facility failed to provide supervision during meal time to prevent choking (a person who has severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) accident (any unexpected or unintentional incident, which resulted or may result in injury or illness to a resident) for one of three sampled residents (Resident 1) who was at risk for choking by failing to: Ensure Certified Nursing Assistant (CNA) 1 did not leave Resident 1's dinner tray unattended in Resident 1's room with Resident 1 and supervised/monitored Resident 1 during mealtime as indicated in Resident 1's Care Plan (CP) titled, Resident Care Plan for Risk for Choking, and the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance. […]

• Actual harm, isolatedF689Jun 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received one-on-one supervision (1:1, one staff supervising 1 resident) to prevent fall (move downward, typically rapidly and freely without control, from a higher to a lower level) as indicated in Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide comprehensive care for Resident 1) Meeting/Care Conference, dated 5/1/2023. On 6/16/2025 at approximately 5:35 pm, Activity Assistant (AA) 1 left Resident 1 unsupervised in Resident 1's wheelchair inside Resident 1's room. […]

• Actual harm, isolatedF684Apr 10, 2025

  Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) ' s body on 3/20/2025 and 3/21/2025 to prevent injury/wound (an injury to living tissue, specifically a break or disruption in the skin or other body tissues caused by an external force) from embedded (implanted, an object fixed firmly and deeply in a surrounding mass) bracelets (ornamental/decorative band, hoop, or chain worn on the wrist or arm). These failures resulted in Resident 1 developing an infected wound (a wound that harbors harmful bacteria, leading to symptoms like increased redness, pain, swelling, and pus) to Resident 1 ' s left wrist. […]