Health inspection·August 14, 2025

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 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.Findings:During a review of Resident 43's admission Record (a document that contains demographic and clinical data), it indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (a long-term condition that involves widespread body pain) and rhabdomyolysis (condition in which damaged skeletal muscle [the main tissue responsible for body posture and movement] breaks down rapidly).A review of Resident 43's physician order, dated July 30, 2025, indicated Percocet [an opioid that binds to specific receptor in the body to give pain relief] . give 1 tablet by mouth every 4 hours as needed for severe pain.During a concurrent interview and record review, on August 14, 2025, at 10:30 AM, with the MDS Nurse, the MDS reviewed Resident 43's Medication Administration record for the months of July and August 2025. The record indicated that Percocet was administered to Resident 43 on July 30, 2025; July 31, 2025; August 1, 2025; and August 2, 2025. The MDS Nurse confirmed Resident 43 received Percocet for a total of four days during an observation period (also known as look back period is the time just before and including the assessment date to assess and document resident condition and care needed).During further concurrent interview and record review, on August 14, 2025, at 10:35 AM, with the MDS Nurse, the MDS Nurse reviewed and acknowledged Resident 43's MDS admission Assessment, dated August 2, 2025, under Section N, titled Medication, which indicated Resident 43 did not receive any opioids during the observation period (from July 26, 2025 to August 2, 2025). The MDS Nurse stated, I should have coded 'yes' to indicate that resident [Resident 43] received an opioid during the observation period, but I did not.During a concurrent interview and record review, on August 14, 2025, at 10:40 AM, with the MDS Nurse, the MDS Nurse reviewed the facility's policy and procedures (P&P) titled Comprehensive Assessment revised October 2023, which indicated Policy statement. Comprehensive assessments are conducted to assist in developing person - centered care plan. Policy interpretation and implementation. 1. The facility conducts comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. The MDS Nurse stated the facility did not follow the policy. During a concurrent interview and record review on August 14, 2025, at 10:43 AM, with MDS Nurse, the MDS Nurse reviewed the facility's P&P titled Certifying Accuracy of The Resident Assessment revised November 2019, which indicated . Policy interpretation and implementation . 3. The information captured on the assessment reflects the status of resident during the observation ( look back) period for that assessment. The MDS Nurse stated the facility manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2024, it indicated, .item rationale. While Residents Affected - Few Page 1 of 10 555910 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assuring that only those medications required to treat the resident's assessed condition are being used, it is important to assess the need to reduce these medications wherever possible and ensure that the medication is the most effective for the resident's assessed condition. Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use during the 7-day look back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home. 555910 Page 2 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0692 Provide enough food/fluids to maintain a resident's health. 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 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.Findings:During a review of Resident 37's admission Record (contains demographic and medical information), it indicated Resident 37 was admitted to the facility on [DATE], with the diagnoses of osteoarthritis (degeneration of the cartilage in single joint, leading to pain, stiffness and reduced range of motion), metabolic encephalopathy (condition where brain dysfunctions from metabolic imbalances such as nutrient intake or toxin buildup) and dysphagia (difficulty swallowing).During a review of Resident 37's Diet Order dated July 9, 2025, it indicated regular diet (healthy meal plan for individuals without specific medical needs or dietary restrictions, providing adequate nutrients and calories from all major food groups), regular texture (normal diet with no mechanical modification), thin liquid consistency.During a concurrent observation and interview, on August 11, 2025, at 9:19 AM, with Resident 37, in Resident 37's room, Resident 37 was lying in bed. Her breakfast was on her bedside table. Resident 37 stated she liked to eat her breakfast late. Resident 37's breakfast contained a cup of coffee, cup of juice, small bowl of cream of wheat, two pancakes and three slices of bacon, with half of a single strawberry.During a concurrent interview and record review, on August 11, 2025, at 9:20 AM, with Resident 37, Resident 37's meal ticket (a piece of paper indicating allergies, preferences and likes/dislikes) was reviewed. It indicated serves only: coffee, toast, cinnamon, margarine, or any other pastries is ok, bacon 2 sls [slices] fresh fruit cup. Resident 37 stated the facility had forgotten her fresh fruit cup. During an interview on August 14, 2025, at 1:09 PM, with the Dietary Supervisor (DS), the DS stated the single strawberry was a garnish. The DS further stated Resident 37 should have received a fresh fruit cup for breakfast on August 11, 2025.During a concurrent interview and record review, on August 14, 2025, at 1:10 PM, with the DS, the facility's policy and procedure (P&P) titled, Resident Food Preferences dated revised July 2017, was reviewed. The P&P indicated, Individual food preferences will be assessed [checked] upon admission. modification to diet will only be ordered with the resident's . consent . 10. The Food Service Department will offer a variety of foods at each scheduled meal. The DS stated the P&P was not followed. Residents Affected - Few 555910 Page 3 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based 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. These failures had the potential to cause contamination (when something harmful, like dirt, germs, or chemicals, mixes with something clean or safe, making it unsafe to use) and reduce confidence in medication efficacy and safety for 59 highly vulnerable residents. Findings:1. During a concurrent observation and interview, on August 12, 2025, at 3:16 PM, in the South Station medication room, with the Infection Prevention Nurse (IPN), the medication refrigerator was inspected. The IPN used a paper towel to wipe the bottom of the medication refrigerator which revealed moist dust build up. The IPN stated the refrigerator was designated for storing all medications that require refrigeration. The IPN further stated all medication storage areas should have been clean to maintain the efficacy and safety of the medications and prevent contamination.During further concurrent interview and record review, on August 12, 2025, at 4:50 PM, with the IPN, the IPN reviewed the facility's policy and procedure (P&P) titled, Storage of Medication, revised November 2020, which indicated, . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The IPN stated the facility did not have a specific cleaning schedule, but all licensed staff were responsible for keeping the medication refrigerator clean in a sanitary manner, which was not done. The IPN further stated the facility policy was not followed.2. During a concurrent observation and interview, on August 13, 2025, at 9:45 AM, with the Treatment Nurse (TN), the TN inspected the contents inside Treatment Cart 2. The TN found three opened and used ointment tubes without documented opened dates which were as follows:i. Silver sulfadiazine cream (prescription topical medicine used to help prevent and treat wound [a break or opening in the skin] infections)ii. Santyl ointment (prescription topical medicine used to help clean and remove dead tissue from the wound)iii. Mupirocin ointment (prescription topical medicine used to treat bacterial skin infections) During further observation and interview, on August 13, 2025, at 10:00 AM, with the TN, the TN acknowledged that the Silver Sulfadiazine cream, Santyl ointment and Mupirocin ointment were opened and used without documentation of when the tubes were opened.During further concurrent interview and record review, on August 14, 2025, at 2:55 PM, with the TN and the Director of Nurse (DON), both the TN and the DON reviewed the facility's P&P titled, Wound Care revised October 2010, which indicated, Purpose. The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation. 3. Assemble the equipment and supplies as need. Date and initial all bottles and jars upon opening. Both the TN and DON acknowledged their unawareness of the requirement to document the opening date on ointments. The DON stated the facility policy was not followed. 555910 Page 4 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based 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). Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet.During a review of the facility recipe for Meatballs / Marinara menu, it indicated Serve meat with a #8 scoop, topped with 4 oz (1/2 cup) of tomato sauce (1 cup total). An observation of the lunch tray line's puree diet preparation was conducted on August 11, 2025, at 11:57AM, in the kitchen. [NAME] 1 used a #10 (3/8 cup) scoop (a specific size of food dish commonly used in food service and baking) to serve the puree meatball with sauce. [NAME] 1 did not use the #8 scoop. During an interview and record review with the Dietary Supervisor (DS), on August 12, 2025, at 2:43 PM, in the kitchen, the DS stated the cook should have served the puree meatball using two #8 scoops (equaling 1 cup) based on what the recipe indicates. During a concurrent interview and record review, with the DS, on August 12, 2025, at 2:45 PM, the DS reviewed the facility recipe for Meatballs / Marinara menu, which indicated Serve meat with a #8 scoop, topped with 4 oz (1/2 cup) of tomato sauce (1 cup total). The DSS stated the menu was not followed and should have been. 555910 Page 5 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based 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. Findings: During a review of the facility's Meal Distribution Report, it indicated Residents 4, 46, and 79 were on puree diet. During a review of the facility recipe for Lemon Herb Chicken, it indicated, Puree Diets: Place portions of meat needed into a food processor. Process to a fine texture. For every 5 portions. Prepare a slurry with 4 tbsp thickener and 1 cup hot liquid. Mix well with a wire whip. Add 1/2 of the slurry to the chicken. Process for 1 minute; if too dry, and more slurry until meat is pudding consistency.During a concurrent observation and interview on August 12, 2025, at 10:32 AM, with [NAME] 1, in the kitchen, [NAME] 1 was preparing pureed food items for lunch. [NAME] 1 stated she was preparing puree food for three residents (Residents 4, 46, and 79). [NAME] 1 put 6 servings of cooked chicken in the food processor and blended. [NAME] 1 added some chicken broth to the blender and blended further. [NAME] 1 did not check for puree consistency before serving. During a test tray observation and interview on August 12, 2025, at 12:20 PM, with the Dietary Services Supervisor (DSS), at the South Nursing station, the test tray was inspected. The pureed lemon herb chicken was crumbly in consistency. It was not smooth, and lump-free. It did not resemble the consistency of a pudding. The DSS stated Yes, the puree chicken consistency is not of a pudding consistency.During an interview on August 13, 2025, at 10:24 AM, with the Registered Dietician (RD), the RD stated, the recipe for the puree lemon herb chicken was not followed and should have been for residents' on puree diet.During a review of the facility document titled, Dysphagia Diet: Puree IDDSI Level 4, dated 2023, it indicated, Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape in a plate. The diet requires no biting or chewing. During a review of the facility document titled Menu dated October 2017, it indicated Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). 555910 Page 6 of 10 555910 08/14/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 54 vulnerable residents whose health conditions are already highly compromised.1. During a review of Resident 80’s “admission Record” (contains demographic and medical information), it indicated Resident 80 was admitted to the facility on [DATE], with the diagnoses of presence of right artificial knee joint (right knee implant) and aftercare following joint replacement surgery. Residents Affected - Some During a review of Resident 80’s “Order Summary Report”, it indicated a physician order for “Enhanced barrier precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) during high contact (things that are touched often by many people) resident care activities secondary to Right knee surgical site” dated August 9, 2025. During an observation on August 12, 2025, at 3:45 PM, Certified Nursing Assistant (CNA 1) exited Resident 33’s room, pushing the vital signs machine (medical device used to measure a patient’s vital signs such as temperature, pulse, blood pressure, and oxygen reading). Without performing hand hygiene (cleaning hands to remove or reduce harmful microorganism, such as washing hands or using alcohol-based rub) nor disinfecting the vital signs machine, CNA 1 entered Resident 80’s room, and donned (put on) a gown. During an interview on August 12, 2025, at 3:48 PM, with CNA 1, CNA 1 stated she did not perform hand hygiene after leaving Resident 33’s room and before entering Resident 80’s room. During a follow up interview on August 12, 2025, at 3:49 PM, with CNA 1, CNA 1 stated she did not disinfect the vital signs machine after using it on Resident 33 and before using it on Resident 80. During a concurrent interview and record review on August 14, 2025, at 1:03 PM, with the Infection Preventionist Nurse (IPN), the facility’s policy and procedure (P&P) titled, “Handwashing/Hand Hygiene”, revised October 2023, was reviewed. The P&P indicated, “This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections… 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections … Indications for Hand Hygiene … 1. Hand Hygiene is indicated: … d. after touching a resident … e. after touching the resident’s environment…” The IPN stated the P&P was not followed. During a concurrent interview and record review on August 14, 2025, at 1:04 PM, with the IPN, the facility’s P&P titled, “Cleaning and Disinfection of Environmental Surfaces” 555910 Page 7 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0880 Level of Harm - Minimal harm or potential for actual harm revised June 2009, was reviewed. The P&P indicated, “Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities… c. Non-critical items are those that come in contact with intact skin but not mucous membranes… (2) Most non-critical items can be decontaminated where they are used…” The IPN stated the P&P was not followed. Residents Affected - Some 2. During a review of Resident 11’s clinical record, the face sheet indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (a bacteria enters the part of body that affects urine), and immunodeficiency (a decreased ability to fight infections and other diseases). During a review of Resident 11’s “Order Summary Report,” dated July 29, 2025, it indicated, “…Enhanced barrier precaution high contact resident care activities secondary to abscess (collection of pus – a liquid, usually yellowish or whitish, that appears when your body is trying to fight off an infection or when a wound isn’t healing properly) to lumbar (five bones in the lower back of the human body) every shift.” During a concurrent observation and interview on August 11, 2025, at 11:13 AM, inside Resident 11’s room, CNA 2 was preparing to perform perineal care for Resident 11. CNA 2 did not perform hand hygiene nor wear PPE upon entering the resident’s room and proceeded to close the door and begin with care. In the middle of starting care, the IPN entered the room and instructed CNA 2 to put on PPE. CNA 2 then donned his gloves and gown and continued rendering care to Resident 11. During a follow-up observation and interview on August 11, 2025, with CNA 2, at 11:22 AM, in Resident 11’s room, CNA 2 and the IPN transferred Resident 11 into a wheelchair. CNA 2 took off the PPE, and without performing hand hygiene, pushed Resident 11’s wheelchair to the common area outside of the room. CNA 2 stated he did perform hand hygiene before providing perineal care for Resident 11. CNA 2 also stated he did not put on PPE before performing perineal care and only wore it after being instructed by the IPN. During further interview, CNA 2 stated after he removed his PPE, he also did not perform hand hygiene. CNA 2 also stated he should have performed hand hygiene and applied PPE to prevent cross-contamination. During a concurrent interview and record review on August 13, 2025, at 1:00 PM, with the IPN, the facility’s P&P titled, “Enhanced Barrier Precautions” revised March 2024 was reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:08 PM, with the IPN, the facility’s P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:24 PM, with the Director of Nursing (DON), the P&P titled, “Enhanced Barrier Precautions” revised March 2024 was 555910 Page 8 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The DON stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:26 PM, with the DON, the P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The DON stated the facility did not follow the P&P. 3. During a review of Resident 7’s clinical record, the face sheet indicated Resident 7 was admitted to the facility on [DATE], with diagnoses including sepsis (an infection that causes the body to damage its organs), urinary tract infection, and immunodeficiency due to drugs. During a review of Resident 7’s “Order Summary Report,” dated July 25, 2025, it indicated, “…Enhanced barrier precaution during high contact resident care activities secondary to foley catheter (a tube that collects urine into a bag) every shift…” During an observation on August 12, 2025, at 12:32 PM, with LVN 1, in front of Resident 7’s room, LVN 1 was preparing Resident 7’s medications for administration. LVN 1 unlocked the medication cart and retrieved a bubble pack (medication packaging) containing Resident 7’s medication. LVN 1 dispensed one tablet from the bubble pack into a medication cup. LVN 1 did not perform hand hygiene before entering Resident 7’s room to administer the medications. During an interview on August 12, 2025, at 12:35 PM, with LVN 1, LVN 1 stated she did not perform hand hygiene after preparing medications and before medication administration. LVN 1 further stated she should have to prevent the spread of MDROs and ensure resident safety. During a concurrent interview and record review on August 13, 2025, at 1:00 PM, with the IPN, the facility’s P&P titled, “Enhanced Barrier Precautions” revised March 2024, was reviewed. The P&P indicated “…2. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) [germs that resist antibiotic treatments] to residents.” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:06 PM, with the IPN, the facility’s P&P titled, “Administering Medications,” revised April 2019, was reviewed. The P&P indicated, …25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable… The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:08 PM, with the IPN, the facility’s P&P titled, “Handwashing/Hand Hygiene,” revised October 2023, was reviewed. The P&P indicated, “…1. Hand hygiene is indicated: a. immediately before touching a resident. c. after contact with blood, body fluids, or contaminated surface .” The IPN stated the facility did not follow the P&P. During a concurrent interview and record review on August 13, 2025, at 1:24 PM, with the DON, the 555910 Page 9 of 10 555910 08/14/2025 Trellis Chino 5454 Walnut Ave Chino, CA 91710

F 0880 Level of Harm - Minimal harm or potential for actual harm facility’s P&P titled, “Administering Medications,” revised April 2019, was reviewed. The P&P indicated, …25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable… The DON stated the facility did not follow the P&P. Residents Affected - Some 555910 Page 10 of 10