Health inspection·January 6, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some 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. Findings: 1. During a review of Resident 4's admission Record (contains demographic and medical information), it indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (condition that affects the way the person's brain is working), seizures (convulsions), and anxiety (feeling of fear, dread and uneasiness). During a concurrent observation and interview, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 8:23 AM, inside Resident 4's room, a position change alarm was observed on Resident 4's left bed rail. The IPN stated Resident 4 had a position change alarm because she was at risk for falls. She further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review with the Director of Nursing (DON), on January 6, 2023, at 8:58 AM, the DON reviewed Resident 4's Order Summary Report, (report that show current physician's orders), dated January 4, 2023, and was not able to find a physician order for Resident 4's use of position change alarm. The DON stated there was no order for it. 2. During a review of Resident 5's admission Record, it indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, and psychosis (mental disorder characterized by a disconnection from reality). During a concurrent observation and interview, with the IPN, on January 5, 2023, at 8:33 AM, inside Resident 5's room, a position change alarm was observed on Resident 5's left bed rail. The IPN stated Resident 5 had a position change alarm because she was at risk for falls. The IPN further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:10 AM, the DON reviewed Resident 5's Order Summary Report, dated January 4, 2023, and was not able to find a Page 1 of 5 555910 555910 01/06/2023 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0604 physician order for Resident 5's use of position change alarm. The DON stated there was no order for it. Level of Harm - Minimal harm or potential for actual harm 3. During a review of Resident 7's admission Record, it indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included dementia, schizophrenia (mental disorder in which people interpret reality abnormally) and bipolar disorder (mental illness that causes extreme mood swings). Residents Affected - Some During a concurrent observation and interview, with the IPN, on January 5, 2023, at 8:33 AM, inside Resident 7's room, a position change alarm was observed on Resident 7's left bed rail. The IPN stated Resident 7 had a position change alarm because he recently had a fall. The IPN further stated position change alarms needed to be ordered by a physician. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:14 AM, the DON reviewed Resident 7's Order Summary Report, dated January 4, 2023, and was not able to find a physician order for Resident 7's use of position change alarm. The DON stated there was not order for it. During a concurrent interview and record review, with the DON, on January 6, 2023, at 9:16 AM, the DON reviewed the facility's undated policy and procedure (P&P) titled, Alarms, use of Position Change Alarm, which indicated, . Is the policy of the facility use the least restrictive method of ensuring resident safety and to provide the highest degree of resident independence possible . 2.To establish activity patterns and routines, use of an alarm will be included on the care plan as a nursing intervention and reviewed quarterly and as necessary by the IDT [Interdisciplinary Team]. A physician order should include checking placement and functioning of the device. The DON stated the facility did not follow the policy. 555910 Page 2 of 5 555910 01/06/2023 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few This failure had the potential to cause inaccuracy in identifying Resident 52's care and support needs. Findings: During a review of Resident 52's admission Record (a document that contains demographic and clinical data), it indicated Resident 52 was admitted to the facility on [DATE], with diagnoses which included cellulitis (a deep infection of the skin caused by bacteria) of right lower limb and type 2 diabetes mellitus (a chronic, metabolic disease characterized by elevated blood sugar level) with foot ulcer (an open sore or wound). During a concurrent interview and record review, with the Treatment Nurse (TN), on January 6, 2023, at 10:30 AM, the TN reviewed Resident 52's Electronic Health Record (EHR) which indicated an admission body assessment was conducted for Resident 52 on November 30, 2022. Further review indicated Resident 52 was assessed with diabetic foot ulcer on her right foot. The TN stated, I remembered, I did the resident admission body assessment, the patient [Resident 52] did not have any pressure injury. During further interview and record review, with TN, on January 6, 2023, at 10:40 AM, the TN reviewed Resident 52's EHR which indicated a weekly body assessment was conducted for Resident 52 on December 7, 2022. Further review indicated Resident 52 was assessed with diabetic foot ulcer on her right foot. The TN stated there were no other skin condition was observed during Resident 52's weekly skin assessment. During a concurrent record review and interview, with the Minimum Data Set Nurse (MDS Nurse), on January 6, 2023, at 2:21 PM, the MDS Nurse reviewed Resident 52's EHR, and was not able to find any documentation that Resident 52 had pressure ulcer. The MDS Nurse acknowledged that there was no other skin condition recorded on Resident 52's EHR besides the diabetic ulcer on her right foor. During further interview and record review, with the MDS Nurse, on January 6, 2023, at 2:30 PM, the MDS Nurse reviewed Resident 52's MDS admission Assessment ( a comprehensive assessment for a resident that must be completed within 14 days after admission), dated December 10, 2022, which indicated under Section M titled Skin Conditions, that Resident 52 was coded to have an unhealed unstageable (unable to see the bottom of the sore to know how deep is the sore) or deep tissue injury (can be dark purple or maroon-colored areas on or under the skin) pressure ulcer. The MDS Nurse stated Resident 52 did not have any unstageable nor deep tissue injury. The MDS Nurse further stated, It was coded in error. During a concurrent interview and record review, with MDS Nurse, on January 6, 2023, at 2:35 PM, the MDS Nurse reviewed the facility's policy and procedures titled Comprehensive Assessment, revised March 2022, which indicated . Comprehensive assessment are conducted to assist in developing person centered care plan .8 . a. the resident's overall clinical status is not accurately represented 555910 Page 3 of 5 555910 01/06/2023 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (i.e. miscoded) on the erroneous assessment and/or result in an inappropriate plan of care . The MDS Nurse stated the facility did not follow the policy. Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2019, indicated .Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer risk assessments. 2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident. 3. Examine the resident and determine whether any ulcers, scars, or non-removable dressings/devices are present . 555910 Page 4 of 5 555910 01/06/2023 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few 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. Findings: During a concurrent interview and record review, with the Infection Preventionist Nurse (IPN), on January 5, 2023, at 9:11 AM, the IPN reviewed the facility provided list of employees and confirmed the following employees have worked on January 4, 2023: a. Certified Nursing Assistant (CNA 1) b. Certified Nursing Assistant (CNA 2) c. Physical Therapy Assistant (PTA) d. Housekeeper (HKP) During a further interview and record review, with the IPN, on January 5, 2023, at 12:10 PM, the IPN reviewed a facility document titled, Facility Screening for Employees or Ancillary Staff (screening log which includes temperature check and signs or symptoms of COVID-19) dated January 4, 2023, indicated CNA 1, CNA 2, PTA, and HKP were not screened for COVID-19 symptoms before entering the facility. The IPN stated upon entering the facility, all employees were expected to be screened for signs and symptoms of COVID-19, and to answer the screening log questions accurately. During a concurrent interview and record review, with the IPN, on January 5, 2023, at 12:55 PM, the IPN reviewed the facility's undated policy and procedure titled Coronavirus (COVID-19) Employee Screening, which indicated, Employee Screening . Prompt identification and isolation of potentially infectious individuals is a critical step in protecting employees, visitors, and others at the facility . Screening process for an employee below . Start of Shift . 2. The employee's temperature will be check utilizing a digital or temporal thermometer . 3. If an employee's temperature is 100.4 or above, the employee will be sent home and no permitted to be in the building or work his or her shift . The IPN stated that facility did not follow the policy. 555910 Page 5 of 5