Chino Valley Health Care: Wound Assessment Failure - CA
Not when the resident was re-admitted on May 26, 2026. Not the following day. The skin reassessment form from the admission date was blank, and the admitting nurse supervisor later told inspectors she had not looked at the surgical site at all.
The resident, identified in inspection records only as Resident 11, had undergone open surgery to repair a displaced fracture of the left thighbone, a procedure in which surgeons insert a metal rod into the bone to hold it in place. The operation left three separate incision sites on the outer left leg: one on the hip secured with four staples, one on the mid-thigh with six staples, and one on the lower thigh with seven staples. Inspectors observed all three wounds themselves during a visit to the resident's room on May 28, 2026, accompanied by a certified nursing assistant.
Resident 11 lacked the capacity to make decisions about their own care, according to a physician evaluation in the medical record.
The registered nurse who supervised the admission, identified in the report as RN 2, told inspectors she was on duty when Resident 11 returned from the hospital. She confirmed she did not assess the surgical wounds. She said it was important to do so, to check for early signs of infection. She had not done it anyway.
A second nurse, RN 1, reviewed the medical record with inspectors the previous afternoon and found the same gap. The skin reassessment form dated May 26 was blank. There was no admission skin assessment anywhere in the chart. RN 1 said assessing the surgical site on arrival was important precisely because unmonitored wounds can become infected.
The Director of Nursing, interviewed the morning of May 28 as inspectors were still in the building, said skin assessments were necessary for all newly admitted residents and especially critical for patients returning from surgery, so that staff could establish a baseline and catch the earliest signs of infection.
The facility's own written policy, last revised in September 2012, required nurses to conduct a physical assessment of the skin upon admission and to complete supplemental skin assessment forms. All relevant data was to be entered into the medical record.
None of that happened for Resident 11.
The inspection, triggered by a complaint, identified the failure as carrying the potential for actual harm, specifically delayed care and treatment for surgical wounds that could lead to infection. The fracture involved the intertrochanteric region of the left femur, the longest bone in the body, and the surgery to repair it was classified as a subsequent encounter for routine healing, meaning Resident 11 was expected to recover. Whether that recovery proceeded without complication from the missed assessment is not addressed in the inspection record.
What the record does show is that a person who could not advocate for their own care came back from major surgery, settled into a room at Chino Valley Health Care Center, and spent at least two days with three stapled incisions that no nurse had formally examined. The form that should have documented the wounds on arrival sat in the chart, empty.
Inspectors cited the facility for failing to ensure Resident 11 received a skin assessment following readmission, a finding that affected one of three residents sampled during the complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chino Valley Health Care Cente from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
CHINO VALLEY HEALTH CARE CENTE in POMONA, CA was cited for violations during a health inspection on May 28, 2026.
Not when the resident was re-admitted on May 26, 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.