Trellis Chino

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the three licensed vocational nurses (LVN 1) held a valid and current license to practice when LVN 1 worked with an expired license from [DATE], through [DATE]. This failure had the potential to place 59 highly vulnerable residents at risk due to LVN 1's non-compliance with the legal requirement to practice nursing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the proper and safe infection control practices were followed when:1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene in between Residents 33 and 80's rooms. CNA 1 did not disinfect vital signs machine in between Resident 33 and 80. 2. CNA 2 did not perform hand hygiene before and after perineal care (cleaning the genital and anal areas) and did not utilize personal protective equipment (PPE - clothing and gear designed to protect you from hazards at work or during certain activities) in isolation room (room used to keep germs from spreading) for Resident 11. 3. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene nor don gloves after medication preparation and before medication administration in an isolation room for Resident 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for one of two residents reviewed for resident assessment (Resident 43). This failure resulted in an inaccurate assessment, potentially leading to a misidentification of Resident 43's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were provided for one of seven residents reviewed for nutrition (Resident 37) when Resident 37 did not receive a fresh fruit cup for breakfast as indicated on meal ticket on August 11, 2025. This failure had the potential to cause nutritional decline and unmet care needs for Resident 37.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to maintain an appropriate environment for storing all drugs and biologicals in accordance with accepted professional principles and the facility's policies and procedures for one of two medication rooms (South Station medication room) and one of two treatment cart (Treatment Cart 2) reviewed for medication storage, when: 1. The medication refrigerator inside the South Station medication room was found to be unsanitary on August 12, 2025. 2. Three opened and used ointments tubes were found without documented opened dates inside Treatment Cart 2 on August 13, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for three residents reviewed for puree diets (Resident 4, 46, and 79) when the incorrect portion size of pureed meatball was served for lunch on August 11, 2025. This failure has the potential to cause unintended weight loss (a noticeable decrease in body weight that occurs without conscious effort, such as dieting or exercising more), and inadequate nutritional needs (a state where the body doesn't receive enough of the essential nutrients it needs to function properly) for medically compromised Residents 4, 46 and 79 on puree diet (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recipes were followed for puree (a modified diet where regular foods are transformed into a smooth, lump-free consistency, resembling pudding) diets for three residents reviewed for puree diet (Residents 4, 46, and 79) when the pureed lemon herb chicken, served for lunch on August 12, 2025, was crumbly and not smooth. This failure had the potential to cause choking and dissatisfaction for Residents 4, 46, and 79 who are medically compromised.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #16 and Resident #40) of 3 sampled residents reviewed for resident assessment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide conduct an assessment and monitor the provision of a nebulizer treatment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to monitor the dialysis fistula for 1 (Resident #165) of 1 sampled resident reviewed for dialysis.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure ordered medication was available in the facility for 1 (Resident #32) of 6sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to store nebulizer equipment for 1 (Resident #165) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure for position change alarm (device place in the bed or wheelchair to alert staff when the person gets out from bed or wheelchair), for three of three residents (Residents 4, 5 and 7) reviewed for falls when position change alarms were used for Residents 4, 5, and 7 without a physician's order. This failure placed Residents 4, 5 and 7 at risk for decreased mobility, sleep disturbances, and agitation in response to the sound of the alarm.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services in the skin conditions for one resident (Resident 52) reviewed for pressure ulcers (an open wound on the skin caused by a long period of constant pressure). This failure had the potential to cause inaccuracy in identifying Resident 52's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of infections and other infectious diseases when four employees was not screened for Covid-19 (a highly infectious disease caused by the SARS-CoV-2 virus] symptoms and exposure upon entering the facility on January 4, 2023. This failure had the potential to cause harm to the 50 residents residing within the facility by causing cross contamination (the transfer of bacteria or viruses from one person to another) of the environment and increasing the risk of exposure and spread of the COVID-19 virus within the facility.