POMONA, CA - State health inspectors documented significant safety and care violations at Chino Valley Health Care Center during a May 2025 inspection, including a resident elopement incident that resulted in immediate jeopardy designation when a cognitively impaired resident left the secured unit unsupervised and went missing for four days.
Resident Missing for Four Days After Security Failures
The most serious violation involved a resident with paranoid schizophrenia, anxiety disorder, and diabetes who eloped from the facility's secured memory care unit on April 24, 2025. The resident, identified in the report as Resident 3, walked out of the facility at 7:06 PM after a certified nursing assistant failed to ensure the secured unit door closed properly behind them.
Surveillance video reviewed by inspectors showed the resident following the staff member through the unlocked door, then proceeding through the facility's main lobby where no receptionist was stationed and the front door alarm was not activated. The resident walked directly onto a busy street with heavy traffic.
The resident was not discovered missing until approximately 9:00 PM that evening - nearly two hours after the elopement occurred. Staff had failed to conduct required 15-minute visual checks that would have identified the resident's absence sooner. Documentation showed blank entries in monitoring logs from 6:45 PM through 11:00 PM on the night of the elopement.
Local police found the resident four days later on April 28 and transported them to a medical clinic. The resident was returned to the facility that afternoon with stable vital signs but required hospital evaluation for further assessment.
Medical Risks of Unsupervised Elopement
The elopement placed the resident at severe risk for multiple serious outcomes. The resident required daily insulin injections for diabetes management, including both rapid-acting and long-acting insulin formulations. Missing these medications for four days could lead to dangerously high blood sugar levels, potentially resulting in diabetic ketoacidosis - a life-threatening complication that can cause coma or death.
The resident also required daily anti-seizure medication (Tegretol) and antipsychotic medication (Zyprexa) for schizophrenia management. Abrupt discontinuation of anti-seizure medication significantly increases seizure risk, which could result in injury from falls, aspiration, or status epilepticus - a medical emergency involving prolonged seizures.
Additionally, the resident's moderate cognitive impairment and active psychiatric symptoms meant they lacked the capacity to make safe decisions or seek help appropriately. The facility's location on a busy street created immediate risk for vehicular accidents, while exposure to temperature extremes over four days posed risks for dehydration, hypothermia, or heat-related illness.
Verbal Abuse Incident Goes Unreported
Inspectors documented another serious violation involving verbal abuse between residents that staff failed to report to administration. On April 29, 2025, a resident with impulse disorder and dementia was observed yelling racial slurs and profanity at another resident with severe cognitive impairment. The victim appeared "visibly scared and emotionally distressed," clutching their wheelchair armrests while stating "I'm scared."
Two certified nursing assistants witnessed the incident but failed to report it properly to supervisors, the Director of Nursing, or Administrator as required by facility policy. One CNA later admitted they "had not reported the incident as thoroughly as [they] should have" and acknowledged that "because of the severity of the language used-including the racial slur and the profanity-the incident should have been reported immediately."
Facility policy requires immediate reporting of suspected abuse within two hours for incidents involving abuse or serious bodily injury. The failure to report prevented proper investigation and intervention, potentially exposing other residents to similar verbal abuse and emotional distress.
Choking Risk During Meal Service
A third major violation involved inadequate supervision of a resident with documented swallowing difficulties. The resident, who had been placed on a pureed diet with thickened liquids due to dysphagia, was observed coughing repeatedly during lunch service on April 28, 2025.
Despite the resident coughing continuously throughout the meal - documented as occurring at least 38 separate times during a 10-minute feeding period - the certified nursing assistant continued attempting to feed the resident rather than stopping and notifying nursing staff. The CNA reported giving the resident water "to see if the coughing would stop" but continued feeding even as coughing persisted.
Persistent coughing during meals indicates potential aspiration, where food or liquid enters the airway instead of the esophagus. This can lead to aspiration pneumonia, a serious lung infection that develops when bacteria from aspirated material colonize the lungs. For elderly residents with compromised immune systems, aspiration pneumonia carries mortality rates between 20-50% and represents one of the leading causes of death in nursing home populations.
The facility's dysphagia protocol specifically required staff to identify signs of swallowing difficulties, differentiate between coughing and choking, and implement appropriate interventions. The protocol emphasized that staff should notify speech therapy for assessment when residents exhibit persistent coughing during meals.
Additional Issues Identified
Inspectors documented several other violations during the survey:
- Missing schizophrenia diagnosis in assessment records for a resident receiving antipsychotic medications, potentially affecting care planning and quality measure reporting - Inadequate communication support for a Mandarin-speaking resident who lacked required bedside communication board despite care plan requirements - Infection control failures when staff provided personal care without required protective equipment for a resident under Enhanced Barrier Precautions for multidrug-resistant organisms - Food safety violations including expired items in kitchen storage and improper ice handling during meal service that could expose all 97 residents to foodborne illness - Inadequate room sizes in 27 resident rooms that failed to meet minimum square footage requirements - Pest control issues with gnats observed in kitchen areas
The facility submitted an Immediate Jeopardy Removal Plan on April 29, 2025, that included staff retraining on elopement prevention, installation of new door keypads, implementation of shift-based head counts in the secured unit, and development of monitoring logs for compliance tracking. State inspectors verified implementation and removed the immediate jeopardy designation that evening, though the facility remains under continued monitoring for compliance with all corrective actions.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.