Trellis Paradise

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the Discharge Summary was completed before obtaining a resident's signature and prescribed discharge medications were appropriately coordinated and transferred with the resident upon discharge for 1 of 36 sampled residents (Resident 118). The deficient practice had the potential to result in an incomplete medical record and discharge instructions, interruption of prescribed medication therapy, lack of continuity of care, delayed treatment, inappropriate billing and medication charges, and adverse clinical outcomes following discharge.

Inspectors wroteBased on interview, record review, and document review nursing staff failed to document physician notification, change in condition, nursing interventions or attempts to obtain a physician order to manage a resident's high temperature (fever) as documented in facility policy for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for harm or adverse outcomes due to delayed medical evaluation and treatment.

Inspectors wroteBased on record review, interview and document review, the facility failed to ensure medical record documentation was complete and accessible for 1 of 5 residents (Resident #1). Findings Include:Resident 1 (R1) was admitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and pneumonia. A Licensed Practical Nurse completed a daily skilled charting form on [DATE] at 11:44 PM, which showed an oral temperature of 102.9 Fahrenheit. The nurse entered the temperature at 8:54 PM.An oral temperature of 98.6 Fahrenheit was entered on [DATE] at 12:39 PM, according to the weights and vitals summary. On an effective date of service progress note dated [DATE], a physician documented acknowledging the resident's fever with recommendations to continue to monitor closely, repeat labs if persistent and Tylenol as needed. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure syringes filled with normal saline used to flush intravenous (IV) catheters were left unattended in two different resident rooms. The deficient practice had the potential to compromise residents' safety and infection control standards since the unsecured items could have been inadvertently misused or contaminated.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) expired food products were discarded; 2) food was labeled, 3) dented cans were removed from use; and 4) perishable food products were properly stored in the walk-in refrigerator. The deficient practices had the potential to increase the risk of bacterial growth and cross-contamination that could cause foodborne illness and jeopardize the health and safety of the residents.

Inspectors wroteBased on observations, document review and staff interview, the facility failed to secure 2 of 4 medication carts and 1 of 2 treatment carts. This deficient practice had the potential to compromise residents' safety and cause harm from unauthorized access to controlled substances.

Inspectors wroteBased on record review, interview, and document review, the facility failed to ensure coordination of care was maintained with the referred home health agency for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for an unsafe discharge.

Inspectors wroteBased on observation and staff interview, the facility failed to protect a residents protected health information. This deficient practice had the potential to cause unauthorized disclosure or misuse of protected health information (PHI). Findings Include: On 03/26/2025 at 10:33 AM, a medication cart was left unattended and unsecured in front of room [ROOM NUMBER] with a 50 milliliter (ml) intravenous bag of Saline with one milligram (mg) of Meropenem (an antibiotic medication) laying on the counter of the cart. The Registered Nurse (RN) responsible for the cart, was in room [ROOM NUMBER] and had left the laptop computer screen on the cart open with the resident name, medication profile and diagnoses of room [ROOM NUMBER]'s resident exposed to the public or other residents walking by. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain proper linen handling procedures. This deficient practice placed patients at risk for exposure to infections. On 3/26/2025 at 8:48 AM, Certified Nursing Assistant (CNA1) was observed walking into room [ROOM NUMBER] with clean linen held beneath the CNA's left arm and up against the staff member's uniform. On 03/26/2025 at 10:40 AM, two CNAs were observed walking out of the linen room while holding clean linen against their chest and uniform. Both CNAs confirmed they were transporting the clean linen to resident rooms. CNA2 acknowledged staff should hold clean linen away from their body or place clean linen in a plastic bag during transport to prevent contamination. [...]

Inspectors wroteBased on observation, interview, document review, and record review, the facility failed to honor resident rights related to the use of incontinence brief and repositioning for 1 of 26 sampled residents (R252). The deficient practice placed the resident at risk for negative psychosocial outcomes and diminished comfort.

Inspectors wroteBased on observation, record review, interview and document review, the facility failed to safeguard the privacy of a resident by posting the body weight on a room's board visible from the hallway for 1 of 26 sampled residents (Resident #203). The deficient practice had the potential to violate the rights of the resident to maintain health information in a private manner.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a total parenteral nutrition TPN (a medical method to directly deliver essential nutrients into the bloodstream to individuals with medical conditions that prevent normal food digestion) was administered by qualified Registered Nurses for 1 of 26 sampled residents (Resident #29). The deficient practice had the potential to expose the resident to medication errors that could cause health complications.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a resident was discharged to a licensed group home per physician order for 1 of 26 samples residents (Resident 161). The deficient practice had the potential to place a resident in an inappropriate care setting.

Inspectors wroteBased on observation, record review, interview and document review, the facility failed to ensure an arm brace and sling were placed for a resident with arm fracture for 1 of 26 sampled residents (Resident #98). The deficient practice could lead to complications such as improper healing, increased pain, reduced mobility, increased risk of further injury, and nerve damage. Fundings include: Resident #98 (R98) R98 was admitted on [DATE], with diagnoses including right humerus fracture. On 09/17/24 in the morning, R98 was lying in bed with a visible bandage on the right upper arm. R98 indicated had suffered a fracture and was experiencing significant pain. R98 was holding the right arm with the left hand and explained should have been wearing a brace to immobilize the fracture but had been removed the previous night by a staff member and could not locate it. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary conditions in the kitchen. The deficient practice could potentially expose residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure IV (intravenous) line insertion and care orders for IV dressing changes for midline and peripherally inserted central catheter (PICC) lines were obtained, transcribed, and implemented for 3 of 20 sampled residents (Residents 10, 18, and 12); a heplock IV (maintains access to the veins if a medication or fluid needs to be administered) dressing was changed as scheduled for 2 of 20 sampled residents (Residents 149 and 4); and partially used NS flushes were discarded for 1 of 20 sampled residents (Resident 38), and a hep lock IV was discontinued for 1 of 20 sampled residents (Resident 4). These deficient practices could potentially lead to an increased risk of infection and compromised residents' health.

Inspectors wroteBased on clinical record review, document review and interview, the facility failed to ensure a resident who lacked decisional capacity did not acknowledge receipt of and sign information acknowledgment sheets provided as a part of the facility's admission paperwork for 1 of 20 sampled residents (Resident (R) 16). This failure had the potential to undermine the rights and best interests of the protected person and the guardian's rights when making decisions for the resident's options for care and treatment needs.

Inspectors wroteBased on observation, clinical record review and interview, the facility failed to ensure a resident who was not clinically appropriate to self-administer medications, did not receive an ordered medication by a family member for 1 of 20 sampled residents (Resident #113). The deficient practice placed the resident at risk of not receiving appropriate medications.

Inspectors wroteBased on observation interview, record review and document review, the facility failed to create a baseline care plan for the care and monitoring of a resident with post knee surgery and a resident with lower extremity edema for 2 of 20 sampled residents (Resident 207 and 210). The deficient practice had a potential for residents not to receive appropriate care interventions based on their diagnoses and assessments.

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure care plan revisions were completed upon readmission of a resident (Resident #13). The deficient practice placed the resident at risk for not receiving appropriate care upon readmission.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure care plan revisions were completed to update dialysis transportation arrangements for a resident (Resident #113). The deficient practice placed the patient at risk for not having appropriate transportation for out of facility treatments.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure: 1) abnormal assessments were conveyed to the primary physician for 1 of 20 sampled residents (Resident 203), the deficient practice prevented appropriate care interventions implemented for a resident with edema; 2) medication refusals and questionable ordered medications were conveyed to the primary physician for 1 of 20 sampled residents (Resident 210), the deficient practice had a potential for an unnecessary medication to be administered; 3) medication was available during the medication pass for 1 of 20 sampled residents (Resident 32), and 4) a Medication Administration Record (MAR) was not signed off before medication administration for 1 of 20 sampled residents (Resident 198). [...]

Inspectors wroteBased on observation, interview, and clinical record review the facility failed to ensure a resident with a swallowing precaution received feeding assistance as ordered (Resident #3). The deficient practice placed a resident at risk for choking or aspiration of food.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure Oxygen orders were followed or clarified for 2 of 20 sampled residents (Residents 10 and 12). This deficient practice could potentially lead to a risk of inadequate or excessive Oxygen levels and complications in the residents' medical conditions.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the blood pressure ordered parameters were followed for the administration of the diuretic medication for 1 of 20 sampled residents (Resident 152). This deficient practice could potentially have led to hypotension, inadequate medication management and an increased risk of adverse reactions or treatment ineffectiveness.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a consent for psychotropic medication was obtained for 1 of 20 sampled residents (Resident 25). The deficient practice prevented a resident/resident's representative from their right to be informed.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent (%) or greater when two errors were identified with 28 opportunities observed, resulting in an error rate of 7.14%. Failure to reduce the medication error rate to less than 5% could lead to an adverse drug reaction from an overdose or underdose, which can cause harm or injury to the resident.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food stored inside the kitchen and in 1 of 2 nourishment refrigerators, were labeled and dated. The deficient practice had a potential for prolonged stored food to be served and posed a risk for gastrointestinal issues for the residents. On 09/27/2023 at 8:50 AM, inside the walk-in refrigerator was a stainless-steel container with a brown liquid inside. The container was not labeled and dated when it was stored. The assistant dietary manager confirmed the finding and indicated all stored food should be labeled and dated. On 09/27/2023 at 9:15 AM, observed at the south hall nourishment room refrigerator, the following items were unlabeled: - [NAME] Daiz Vanilla ice cream - bottle of mayonnaise - bottle protein drink - pitcher of tea colored fluid The signage at the door of the refrigerator read as: [...]

Inspectors wroteBased on interview, clinical record review and document review the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident could understand for 3 of 20 sampled residents (R100, 106, and 98). The deficient practice had the potential to obstruct each resident's ability to make a well-informed decision about signing the arbitration agreement.