POMONA, CA - Chino Valley Health Care Center was cited for serious safety violations during a state inspection in May 2025, including a resident elopement that resulted in immediate jeopardy status and failure to report incidents of verbal abuse involving racial slurs between residents.
Resident Escapes from Secured Unit
The most severe violation occurred on April 24, 2025, when a cognitively impaired resident with a known elopement risk managed to escape from the facility's secured unit and remained missing for four days. The incident resulted in an immediate jeopardy citation, indicating the violation posed a serious risk of injury, harm, or death to residents.
Resident 3, who had diagnoses including paranoid schizophrenia, anxiety disorder, and diabetes, was supposed to be monitored every 15 minutes according to his care plan. The resident had previously demonstrated exit-seeking behaviors and had expressed delusions about someone waiting for him outside the facility.
Surveillance video revealed that at 7:06 PM on April 24, a Certified Nursing Assistant (CNA) exited the secured unit without ensuring the door closed behind them. Resident 3 followed the staff member out, walked through the lobby, and exited through the main entrance onto a busy street. The facility's front desk was unstaffed at the time, and the main entrance door was neither locked nor alarmed.
The resident's absence wasn't discovered until between 8:40 PM and 9 PM that evening. Police found Resident 3 four days later and transported him to a local clinic for evaluation before returning him to the facility.
Multiple Safety Protocol Failures
The elopement revealed several critical breakdowns in safety protocols. The monitoring log showed blank entries for Resident 3's whereabouts from 6:45 PM to 11 PM on the day of the incident. The assigned CNA admitted to not checking if the secured unit door closed properly and acknowledged the importance of ensuring doors remain locked after staff exit.
CNA 7, who was responsible for monitoring Resident 3, stated it was "unrealistic to monitor and document the residents' location every 15 minutes because CNA 7 was busy assisting and providing care to other residents." This admission highlighted staffing or time management issues that compromised resident safety.
The facility's location on a busy street with constant vehicle traffic created additional danger for the escaped resident, who required constant medical attention and was unable to care for himself due to his cognitive impairment and medical conditions.
Medical Significance of Elopement Risk
Elopement represents one of the most serious safety risks in long-term care facilities, particularly for residents with cognitive impairments. Residents with dementia, schizophrenia, and other mental health conditions may become disoriented and unable to find their way back to safety. The medical consequences can be severe and potentially fatal.
For residents requiring regular medication like Resident 3, who was prescribed insulin for diabetes and anti-seizure medication, missing doses can lead to dangerous blood sugar fluctuations or seizures. Exposure to extreme temperatures poses additional risks of hypothermia or heat-related illness, particularly for elderly residents whose bodies may not regulate temperature effectively.
The facility's secured unit exists specifically to protect vulnerable residents who lack the cognitive ability to understand danger or make safe decisions. When these protective measures fail, residents face risks including traffic accidents, falls, dehydration, medication complications, and becoming victims of crime or exploitation.
Verbal Abuse Incident Goes Unreported
The inspection also documented a separate incident involving verbal abuse between residents that was not properly reported to facility administration. On April 29, 2025, during an observation by state inspectors, Resident 23 directed racial slurs and profanity toward Resident 47, causing visible distress to the targeted resident.
Resident 47 appeared "visibly scared and emotionally distressed" and stated "I'm scared" while Resident 23 shouted profanities and racial slurs. Despite the severity of the language used, the incident was not reported through proper channels to facility leadership.
Both the Administrator and Director of Nursing confirmed they had not been notified of the incident. The Administrator emphasized that racial slurs and verbal abuse should trigger immediate supervisor notification and facility investigation. The facility's abuse reporting policy requires immediate notification to administration for any suspected abuse incidents.
A CNA who witnessed the incident acknowledged not reporting it thoroughly, stating they may have mentioned yelling to another staff member but did not explain the specific language used or the racial nature of the abuse.
Impact on Vulnerable Residents
Both incidents involved residents with significant cognitive impairments who were particularly vulnerable to harm. Resident 23 had diagnoses including impulse disorder and dementia, while Resident 47 had dementia, anxiety disorder, and restlessness. These conditions can make residents less able to protect themselves from threatening situations or understand appropriate social boundaries.
Verbal abuse involving racial slurs can cause psychological trauma, particularly for residents with anxiety disorders or dementia who may not fully understand why they are being targeted. The failure to address such incidents promptly can create an environment where vulnerable residents feel unsafe and unprotected.
Industry standards require nursing homes to maintain environments free from abuse and to investigate any allegations immediately. Facilities must have systems in place to protect residents from resident-to-resident abuse and to address behavioral issues that may put other residents at risk.
Immediate Corrective Actions
Following the identification of immediate jeopardy, the facility implemented several corrective measures. Staff received mandatory training on elopement prevention policies, including the importance of ensuring doors close after exiting secured areas and conducting required 15-minute monitoring rounds.
The facility assigned a staff member to the reception area to supervise facility entrances and exits, installed a new door keypad system for the front lobby, and implemented head counts at every shift change in the secured unit. Virtual alert signs were posted at secured exit areas to remind staff about door closure protocols.
Monthly elopement training was scheduled for three months, and an elopement monitoring log was developed to track supervision activities and door alarm status. The facility also created a Quality Assurance and Performance Improvement plan specifically addressing elopement prevention.
Additional Issues Identified
The inspection revealed other concerning patterns in resident care and facility operations. The elopement incident highlighted potential staffing adequacy issues, as the assigned CNA indicated difficulty maintaining required monitoring schedules due to competing care responsibilities.
The unreported verbal abuse incident suggested gaps in staff training regarding incident recognition and reporting procedures. Communication breakdowns between direct care staff and facility leadership created situations where serious incidents involving resident safety and dignity were not addressed promptly.
Documentation deficiencies were apparent in the monitoring logs, which showed blank entries during critical time periods when residents required supervision. These gaps in record-keeping made it difficult to track resident whereabouts and ensure care plan requirements were being met.
The facility's response to both incidents demonstrated the importance of having robust safety systems and reporting protocols in place to protect vulnerable residents and ensure appropriate oversight of care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chino Valley Health Care Cente from 2025-05-01 including all violations, facility responses, and corrective action plans.
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