POMONA, CA - A May 2025 state inspection of Chino Valley Health Care Center uncovered a disturbing incident of resident-to-resident verbal abuse involving racial slurs and profanity, followed by the facility's failure to report the incident within the required two-hour timeframe mandated by federal regulations.
Racial Slurs Directed at Resident in Hallway Confrontation
On April 29, 2025, at approximately 12:07 PM, a state surveyor conducting routine investigative tasks at the facility witnessed a confrontation between two residents in the facility's corridor. According to the inspection report, Resident 23, a male resident with diagnoses including impulse disorder, dementia, and unspecified mood disorder, directed profanity and a racial slur at Resident 47, a female resident with dementia, restlessness and agitation, and anxiety disorder.
The surveyor observed Certified Nursing Assistant (CNA) 8 wheeling Resident 47 away from the Northwest area of the facility. Resident 47 appeared visibly scared and emotionally distressed, with her body tense as she clutched the armrest of her wheelchair. The inspection report documented that Resident 47 audibly stated, "I'm scared."
Resident 23 was standing in the doorway of his room and appeared angry, with his face red and his body language tense. Upon seeing the surveyor, Resident 23 immediately yelled, "I want my fuing lunch tray!" in a loud and angry tone. The resident then directed a racial slur and profanity toward Resident 47, shouting, "Get that fuing nier bch away from me!"
The language was overheard by Resident 47, CNA 9, and other unidentified residents in the area. CNA 9 immediately intervened, telling Resident 23 in a firm but calm voice, "You may not speak to other residents like that. That is not respectful!"
Staff Acknowledged Pattern of Abusive Behavior
Interviews with facility staff revealed that Resident 23's behavior was not an isolated incident. During an interview on April 30, 2025, CNA 8 confirmed that she had heard Resident 23 use racial slurs and obscenities in the past, sometimes directed toward staff or other residents.
CNA 8 told investigators that this behavior "usually occurred when Resident 23 was frustrated, such as when he did not receive what he wanted right away, especially food or care." The nursing assistant noted that Resident 23 "got loud, started yelling, and used curse words" during these episodes.
Significantly, CNA 8 stated that the altercation between the two residents could have been prevented with better monitoring. According to the inspection report, CNA 8 stated "the altercation between Resident 23 and Resident 47 could have been avoided if there had been more staff monitoring the hallway, especially around lunchtime." The staff member further noted that "the facility was aware of Resident 23's behavior history, and lunchtime was a high-risk period" due to similar behavior being observed in the past.
In a telephone interview on May 1, 2025, CNA 9 confirmed that Resident 23 used both profanity and a racial slur directed at Resident 47. CNA 9 described the statement as "loud, aggressive, and directed at Resident 47." The nursing assistant characterized the language as constituting verbal abuse, emphasizing that "no one should be spoken to in that manner, especially not by another resident."
CNA 9 told investigators that Resident 47 "did not deserve that treatment because Resident 47 was simply in the hallway and the incident clearly shook-up Resident 47."
Facility Administrator Acknowledges Incident Constituted Verbal Abuse
During an interview on April 30, 2025, the facility Administrator acknowledged the seriousness of the incident. The Administrator stated that had she been made aware of the incident at the time it occurred, she would have initiated the appropriate steps to address it.
The Administrator confirmed that "considering what had reportedly been said, the incident did indicate verbal abuse toward another resident." She characterized the language used as "offensive, discriminatory, and emotionally harmful," stating that it "should have been addressed promptly and thoroughly" following the facility's internal protocols.
The facility maintained policies regarding resident-to-resident interactions involving inappropriate, offensive, or abusive language, according to the Administrator.
Medical Context: Why Verbal Abuse Poses Serious Risks for Dementia Patients
The incident is particularly concerning given the cognitive vulnerabilities of both residents involved. Resident 47's medical records indicated she had dementia with moderately impaired cognition, along with restlessness, agitation, and anxiety disorder. Her Minimum Data Set assessment from February 2025 indicated she required partial to moderate assistance with activities of daily living and mobility.
For individuals with dementia and anxiety disorders, exposure to aggressive verbal confrontations can trigger significant psychological distress. Anxiety disorders cause excessive and persistent worry and fear, often leading to physical symptoms and difficulties in daily life. When a person with these conditions is subjected to verbal abuse, the experience can exacerbate existing symptoms and lead to increased agitation, sleep disturbances, and behavioral changes.
Resident 23's diagnoses also played a role in the incident. Impulse disorder is characterized as a group of behavioral conditions that make it difficult to control actions or reactions. Combined with dementia and mood disorder, these conditions can contribute to unpredictable outbursts. However, federal regulations require facilities to implement care plans and interventions to protect other residents from such behaviors, particularly when patterns of concerning behavior have been documented.
The documentation that lunchtime was a known "high-risk period" for behavioral incidents, combined with staff acknowledgment that the facility was aware of Resident 23's behavior history, suggests that preventive measures could and should have been in place to reduce the likelihood of such confrontations.
Failure to Report Abuse Within Required Timeframe
Beyond the incident itself, investigators cited the facility for failing to report the suspected abuse within the required two-hour window mandated by federal regulations and the facility's own policies.
According to federal guidelines under F609, nursing facilities must timely report suspected abuse, neglect, or theft and report the results of any investigation to proper authorities. The facility's policy and procedure titled "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating" establishes specific timeframes for reporting such incidents.
This failure to report in a timely manner prevented the initiation of an immediate investigation and the implementation of appropriate protective measures for Resident 47. Delayed reporting can allow patterns of abuse to continue unchecked and may leave vulnerable residents exposed to additional harmful incidents.
The facility's own policy, titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revision dated April 2021, clearly states that "residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation." This includes freedom from verbal and mental abuse.
Industry Standards for Resident Protection
Federal regulations require nursing homes to develop and implement comprehensive abuse prevention programs that include staff training, identification of high-risk situations, and protocols for intervention. When residents with cognitive impairments display patterns of aggressive behavior toward other residents, facilities are expected to:
Develop individualized care plans that address behavioral triggers and outline specific interventions to prevent incidents. For Resident 23, whose behavior patterns were known to staff, this should have included increased monitoring during high-risk periods such as mealtimes.
Provide adequate staffing in common areas and corridors, particularly during known peak activity times. CNA 8's statement that the incident could have been prevented with more staff monitoring the hallway underscores a potential staffing or supervision gap.
Separate residents when necessary to prevent harmful interactions. When a resident has a documented history of verbal aggression toward others, facilities must take proactive steps to minimize contact with potential victims.
Train staff on de-escalation techniques and ensure they understand reporting requirements. While CNA 9 appropriately intervened during the incident, the failure to report within two hours suggests a breakdown in communication or understanding of reporting protocols.
Document and report all incidents promptly to allow for investigation and implementation of corrective measures. Timely reporting is essential not only for regulatory compliance but for protecting residents from future harm.
Inspection Findings and Regulatory Classification
The violations were cited under F600 (Free from Abuse and Neglect) and F609 (Timely Reporting of Suspected Abuse). Both deficiencies were classified at "Level of Harm - Minimal harm or potential for actual harm" with "Residents Affected - Few."
While the regulatory classification indicates the harm level was considered minimal, the psychological impact on Resident 47, who was observed to be visibly scared and stated "I'm scared," suggests that the emotional consequences of the incident were significant for the victim.
Additional Issues Identified
The inspection findings highlight broader systemic concerns at the facility:
- Inadequate hallway monitoring during high-risk periods, despite staff awareness of behavioral patterns - Failure to implement preventive measures for a resident with documented history of verbal aggression - Communication gaps that prevented timely reporting of the incident to appropriate authorities - Potential staffing concerns as suggested by staff statements about insufficient monitoring
The inspection was conducted as a complaint survey, indicating that concerns had been raised about the facility prior to the May 1, 2025 inspection date. Chino Valley Health Care Center is located at 2351 S Towne Avenue in Pomona, California.
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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