Inspection Reports for
Chino Valley Healthcare Center

The facility failed to maintain safe food handling practices by not consistently checking and logging temperatures of refrigerators, freezers, and food items served to residents, including milk, gravy, and fish. Temperatures of some refrigerators and freezers were above safe limits, potentially putting residents at risk for food-borne illnesses.

The facility failed to consistently check and log temperatures of refrigerators, freezers, and food items served to residents, resulting in unsafe food temperatures that could potentially cause food-borne illnesses. Specific issues included freezer and fridge temperatures above safe limits and failure to check temperatures of gravy, milk, and fish before serving.

The facility failed to provide adequate privacy during perineal care and diaper changes for two sampled residents, as privacy curtains were not fully closed, leaving residents visible to others. This failure had the potential to cause embarrassment and loss of self-esteem for the residents.

The facility failed to provide adequate privacy during perineal care and changing of incontinence briefs for two sampled residents, exposing them to potential embarrassment and loss of self-esteem. Privacy curtains were not fully closed during care, violating the facility's policy on resident dignity and privacy.

The complaint investigation found that a Certified Nurse Assistant did not wash or sanitize hands after exiting Resident 1's shower room and before touching Resident 2, risking cross contamination. Interviews with staff confirmed the importance of hand hygiene and acknowledged the failure to comply.

The facility failed to ensure infection control practices were followed when a Certified Nurse Assistant did not perform hand hygiene after exiting one resident's shower room and before touching another resident, posing a risk of cross contamination and infection spread.

The facility failed to ensure proper infection control practices when a Certified Nurse Assistant did not perform hand hygiene between resident contacts, posing a risk of cross contamination and infection spread.

The complaint investigation found that Licensed Vocational Nurse (LVN) 1 discharged Resident 1 on 5/29/2025 without conducting a skin check, resulting in a missed diagnosis of a skin rash. Family member reported discovering bleeding scabs after discharge. The deficiency was substantiated based on interviews and record reviews.

The facility failed to conduct a required skin check on Resident 1 prior to discharge, resulting in delayed treatment of a widespread skin rash. Interviews and record reviews confirmed the omission and the potential for physical decline.

The complaint was substantiated. Resident 1 was discharged without a skin check, and family members discovered a rash with bleeding scabs at home. Licensed staff admitted the skin check was not performed as required.

The facility failed to identify a skin rash on Resident 1 when discharged without a skin check, resulting in delayed treatment and potential physical decline. Interviews and record reviews confirmed the skin check was not performed or documented as required by facility policy.

The complaint investigation found that the STAT x-ray ordered on 6/6/2025 for Resident 1 was not performed timely due to the radiology technician's failure to inform staff that the x-ray was not completed. The resident was reported combative and uncooperative. The facility staff did not receive timely notification, delaying necessary care.

The facility failed to ensure that Resident 1 received a STAT x-ray of the left hand in a timely manner as ordered on 6/6/2025. The radiology technician did not perform the x-ray due to the resident being combative and did not inform the facility staff, resulting in delayed care.

The complaint investigation found that the STAT x-ray ordered on 6/6/2025 was not performed due to the resident being combative and uncooperative. The radiology technician failed to notify facility staff of the inability to perform the x-ray. The facility staff did not follow up promptly, resulting in delayed diagnostic services.

The facility failed to ensure that Resident 1 received a STAT x-ray of the left hand in a timely manner as ordered on 6/6/2025. The radiology technician did not perform the x-ray due to the resident being combative and did not inform the facility staff, resulting in delayed care.

The complaint investigation was substantiated. Resident 23 verbally abused Resident 47 using racial slurs and profanity on 4/29/2025. The facility failed to report the incident timely to the administrator and appropriate authorities. Resident 3 eloped from the secured unit on 4/24/2025 at 7:06 PM due to failure of staff to lock doors, monitor the resident every 15 minutes, and supervise the secured unit exit. Immediate jeopardy was identified and removed after corrective actions.

The facility failed to protect Resident 47 from verbal abuse by Resident 23, who used racial slurs and profanity. The facility also failed to timely report the verbal abuse incident. Additionally, the facility failed to prevent Resident 3, who was at risk for elopement, from leaving the secured unit due to inadequate supervision, unlocked doors, and failure to monitor the resident every 15 minutes as required.

The facility was found deficient in multiple areas including failure to ensure resident privacy during care, failure to prevent verbal abuse and timely report it, inaccurate resident assessment data, failure to implement care plans to prevent aspiration, lack of communication aids for non-English speaking residents, failure to prevent resident elopement resulting in immediate jeopardy, inadequate staff knowledge of abuse recognition and reporting, improper food storage and handling, failure to maintain infection control protocols, and insufficient resident room space.

The complaint investigation was substantiated. Resident 23 verbally abused Resident 47 using racial slurs and profanity on 4/29/2025, witnessed by staff and residents. The facility failed to intervene promptly and failed to report the incident within two hours as required. Additionally, Resident 3 eloped from the secured unit on 4/24/2025 due to inadequate supervision and security failures.

The facility failed to prevent verbal abuse by one resident toward another and failed to timely report the abuse. Additionally, the facility failed to prevent the elopement of a cognitively impaired resident from the secured unit due to inadequate supervision, unlocked doors, and failure to monitor the resident as required.

The facility was found deficient in multiple areas including resident privacy violations, failure to prevent verbal abuse, failure to timely report abuse, inaccurate resident assessment coding, failure to implement care plans to prevent aspiration, lack of communication aids for non-English speaking residents, elopement of a cognitively impaired resident, improper food storage and handling, infection control breaches, inadequate room sizes, and pest control issues.

The complaint investigation found that the facility did not report an alleged abuse incident involving Resident 1 within the required two-hour timeframe to the California Department of Public Health, the Ombudsman, and local law enforcement. Staff interviews revealed lack of knowledge about abuse reporting requirements and delays in reporting the incident.

The facility failed to report an allegation of abuse for Resident 1 to the California Department of Public Health, the Ombudsman, and local law enforcement within two hours, resulting in delayed notification and potential risk of abuse. Additionally, two staff members did not understand the facility's abuse reporting policies, which could contribute to further risk of resident abuse.

The complaint involved an allegation that CNA 2 physically and verbally abused Resident 1 on 3/31/2025. The facility did not report the incident to the required authorities within two hours as mandated. The allegation was substantiated by interviews and a written statement from CNA 1.

The facility failed to report an allegation of abuse for one resident to the appropriate authorities within the required two-hour timeframe. Additionally, some staff did not understand the facility's abuse reporting policies and procedures, which could lead to potential resident harm.

The complaint investigation substantiated that the office assistant worked as the Director of Staffing Development without a valid nursing license from at least October 2023 to April 2024, administering medications and monitoring residents, which is not permitted and posed a safety risk.

The facility failed to ensure that a staff member (previous Director of Staffing Development/office assistant) did not work without a nursing license from October 2023 to April 2024 while providing direct care and medication administration to nine sampled residents. This posed a potential risk to resident safety. The staff member's license was surrendered and expired without notification to facility administration.

The facility failed to follow its policy and procedure regarding licensure and certification of personnel, allowing an unlicensed individual to work in a nursing role and provide direct patient care, including medication administration and monitoring, to nine sampled residents. This posed a potential risk to resident safety. The unlicensed staff member's license was surrendered and expired, but the individual continued to work in a licensed capacity without disclosure to administration.

The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy during care, inaccurate resident assessments, failure to revise care plans, inadequate communication competencies among staff, failure to monitor psychotropic medication side effects, medication administration errors, improper food storage and labeling, and insufficient resident room space per regulatory standards.

The facility was found deficient in multiple areas including failure to ensure resident dignity during care, inaccurate resident assessments, incomplete care plan revisions, inadequate communication competencies among staff, failure to monitor psychotropic medication side effects, medication administration errors, improper food storage and labeling, and insufficient resident room space.

The complaint was substantiated. Resident 2 reported waiting up to an hour for assistance after pressing the call light, resulting in soiling herself. Staff interviews and observations confirmed the failure to respond appropriately to the call light.

The facility failed to answer a call light for one of four sampled residents, resulting in the resident waiting up to an hour and soiling herself. Staff interviews confirmed that turning off call lights without checking on residents was unacceptable and against facility policy.

Complaint investigation found that Resident 2's call light was turned off by CNA 1 without assistance being offered. Resident reported waiting up to an hour and soiling herself. Staff interviews and Director of Nurses confirmed the failure to respond properly to call lights.

The facility failed to answer a call light for one of four sampled residents, resulting in the resident waiting up to an hour and soiling herself. Staff interviews confirmed that turning off call lights without checking on residents was unacceptable and contrary to facility policy.

The facility was found deficient in maintaining a homelike environment, ensuring safety to prevent falls, providing appropriate continence care, following safe food storage practices, implementing infection prevention and control, and meeting minimum room size requirements. Several residents' rooms had maintenance issues such as graffiti, chipped paint, and missing caulking. Safety hazards included clutter on floor mats intended to prevent falls. One resident was not placed on a toileting program as indicated by the care plan. Food storage violations included expired items, improper labeling, and personal items stored in food areas. Infection control lapses involved unlabeled urinals and cups in resident bathrooms. The facility requested waivers for 27 resident rooms that did not meet minimum square footage requirements but demonstrated adequate space and care.

The facility was found deficient in maintaining a homelike environment, ensuring resident safety, proper food storage, infection control, and room size requirements. Multiple residents were affected by environmental maintenance issues, unsafe fall risk conditions, inadequate toileting programs, improper food handling, and infection control lapses.