Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Trellis Chino during CMS and state inspections, most recent first.
A facility allowed an LVN to work 14 shifts with an expired nursing license, contrary to its own job description requiring a current, active license. The LVN reported believing the license was still active and was unaware it had expired until it was renewed 22 days after the expiration. A review of state licensing records confirmed the license had gone delinquent and inactive due to failure to renew, and the DON acknowledged that the facility’s requirement for an active license was not followed, potentially affecting 59 highly vulnerable residents.
Staff failed to follow infection control protocols, including hand hygiene and use of PPE, during care and medication administration for multiple residents with enhanced barrier precautions ordered due to conditions such as joint replacement, abscess, and immunodeficiency. These lapses included not disinfecting equipment between residents, not performing hand hygiene before and after resident contact, and not donning PPE as required.
A resident with chronic pain conditions received opioid medication during the MDS observation period, but the MDS assessment was inaccurately coded to indicate no opioid use. The MDS Nurse confirmed the error and acknowledged that facility policy requiring accurate and comprehensive assessments was not followed.
A resident with multiple medical conditions did not receive a fresh fruit cup for breakfast as indicated on her meal ticket, despite facility policy requiring adherence to food preferences. The Dietary Supervisor confirmed the omission and acknowledged that the policy was not followed.
Surveyors found that a medication refrigerator was unsanitary and that three opened ointment tubes on a treatment cart were missing documented opened dates. The IPN confirmed the refrigerator was used for medication storage and should have been kept clean, while the TN and DON acknowledged they were unaware of the policy requiring opened ointments to be dated and initialed. These failures were not in accordance with facility policies and affected 59 residents.
Three residents on puree diets were served incorrect portion sizes of pureed meatball at lunch when staff used a smaller scoop than required by the facility's recipe. The Dietary Supervisor confirmed that the menu instructions were not followed, resulting in the residents not receiving the prescribed amount of food.
Staff did not follow the prescribed recipe for pureed lemon herb chicken, resulting in a crumbly, non-pudding consistency that did not meet the dietary needs of three residents on pureed diets. The issue was confirmed by dietary staff and the RD, and the deficiency was identified through observation and record review.
The facility failed to transmit discharge MDS assessments for two residents within the required timeframe, as mandated by federal and state guidelines. The MDS Nurse, DON, and Administrator acknowledged the delay in submission, which did not comply with the Resident Assessment Instrument Manual requirements.
A resident with respiratory issues did not receive proper assessment and monitoring during nebulizer treatment. The facility's policy required documentation of vital signs and treatment tolerance, but records lacked this information. Staff interviews confirmed the absence of necessary assessments and documentation.
A resident with end-stage renal disease requiring hemodialysis was not properly monitored for the status of their dialysis fistula. Facility policy required regular assessment of the access site for signs of infection and patency, including checking for thrill and bruit. However, documentation was lacking, and interviews revealed that staff often forgot to perform or document these assessments, leading to a deficiency in care.
A resident with paraplegia and moderate cognitive impairment required nystatin-triamcinolone cream for moisture-associated skin damage, but the medication was unavailable for several days. Despite the order being placed, staff failed to follow up with the pharmacy and physician, resulting in a delay in treatment. Interviews with LVNs and the DON highlighted the lack of communication and follow-up regarding the medication's unavailability.
A resident with respiratory care needs had their nebulizer equipment improperly stored, contrary to facility policy. Despite requiring regular nebulizer treatments, the equipment was observed on multiple occasions left on the nightstand without being stored in a plastic bag. Staff, including LVNs, CNAs, the DON, and the Administrator, confirmed the equipment should be stored in a plastic bag when not in use.
Unlicensed LVN Worked Multiple Shifts with Expired License
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) held a valid and current license while working, resulting in one LVN working with an expired license for multiple shifts. A letter from the Board of Vocational Nursing and Psychiatric Technicians showed that the LVN’s license became delinquent and inactive after it was not renewed, and it was not renewed again until 22 days after its expiration. Review of the facility’s Nursing Staff Assignment and Sign-in Sheets showed that this LVN worked 14 shifts during the period when the license was expired. In a telephone interview, the LVN stated she believed she was working with an active license and was unaware it had expired. During a concurrent interview and record review, the DON confirmed that the facility’s job description for LPN/LVN required a current, unencumbered, active license to practice in the state and acknowledged that this requirement was not followed. This failure had the potential to place 59 highly vulnerable residents at risk due to the LVN’s non-compliance with the legal requirement to practice nursing.
Failure to Follow Infection Control Practices During Resident Care and Medication Administration
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control practices during resident care activities, as observed and documented by surveyors. In one instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene after leaving one resident's room and before entering another's, nor did the CNA disinfect the vital signs machine between uses on two different residents. The facility's policies required hand hygiene after touching a resident or their environment and disinfection of non-critical items, but these were not followed, as confirmed by the Infection Preventionist Nurse (IPN). In another case, a CNA did not perform hand hygiene or don personal protective equipment (PPE) before providing perineal care to a resident in an isolation room, despite physician orders for enhanced barrier precautions due to the resident's abscess and immunodeficiency. The CNA only donned PPE after being instructed by the IPN and failed to perform hand hygiene after removing PPE and before moving the resident to a common area. Both the IPN and Director of Nursing (DON) confirmed that facility policies regarding enhanced barrier precautions and hand hygiene were not followed during these care activities. Additionally, a Licensed Vocational Nurse (LVN) did not perform hand hygiene or don gloves after preparing medications and before administering them to a resident in an isolation room, despite orders for enhanced barrier precautions due to the resident's medical conditions, including sepsis and immunodeficiency. The LVN acknowledged the lapse, and both the IPN and DON confirmed that the facility's policies on medication administration, hand hygiene, and enhanced barrier precautions were not followed. These failures were observed to have the potential to result in cross-contamination among vulnerable residents.
Inaccurate MDS Assessment Due to Omission of Opioid Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was completed accurately for a resident admitted with diagnoses including fibromyalgia and rhabdomyolysis. The resident had a physician's order for Percocet to be administered as needed for severe pain, and the Medication Administration Record showed that the resident received Percocet on four separate days during the observation period. However, the MDS admission assessment incorrectly indicated that the resident did not receive any opioids during the look-back period. The MDS Nurse confirmed during interviews and record reviews that the assessment should have been coded to reflect opioid administration but was not. Further review of the facility's policies and procedures revealed requirements for comprehensive, accurate, and standardized assessments, as well as for ensuring that the information captured on the assessment reflects the resident's status during the observation period. The MDS Nurse acknowledged that the facility did not follow these policies. Additionally, the CMS RAI manual was referenced, which outlines the need to review medical records for medication administration during the look-back period. The failure to accurately document opioid administration resulted in an inaccurate assessment of the resident's care and support needs.
Failure to Provide Resident Food Preferences at Breakfast
Penalty
Summary
A resident with diagnoses including osteoarthritis, metabolic encephalopathy, and dysphagia was admitted to the facility and had a diet order for a regular diet with regular texture and thin liquid consistency. On the morning of the deficiency, the resident was observed in her room with her breakfast, which included coffee, juice, cream of wheat, pancakes, bacon, and half of a single strawberry. The resident stated she liked to eat breakfast late and, upon review of her meal ticket, it was noted that her preferences included a fresh fruit cup, which was not provided. The resident confirmed that the facility had forgotten her fresh fruit cup. The Dietary Supervisor confirmed that the single strawberry was only a garnish and that the resident should have received a fresh fruit cup as indicated on her meal ticket. Review of the facility's policy and procedure on resident food preferences showed that individual food preferences are to be assessed upon admission and a variety of foods offered at each meal. The Dietary Supervisor acknowledged that the policy was not followed in this instance, resulting in the resident not receiving her preferred food item.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified two deficiencies related to medication storage and labeling. In the South Station medication room, the medication refrigerator was found to be unsanitary, with moist dust buildup observed during an inspection. The Infection Prevention Nurse (IPN) confirmed that the refrigerator was designated for storing all medications requiring refrigeration and acknowledged that all medication storage areas should be kept clean to maintain medication efficacy and safety. The facility's policy required nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner, but there was no specific cleaning schedule in place, and the policy was not followed. Additionally, in Treatment Cart 2, three opened and used ointment tubes—Silver sulfadiazine cream, Santyl ointment, and Mupirocin ointment—were found without documented opened dates. The Treatment Nurse (TN) and Director of Nursing (DON) reviewed the facility's wound care policy, which required all bottles and jars to be dated and initialed upon opening. Both the TN and DON acknowledged they were unaware of this requirement, and the policy was not followed. These deficiencies affected the storage and labeling of medications and ointments for 59 highly vulnerable residents.
Failure to Follow Prescribed Puree Diet Portion Sizes
Penalty
Summary
The facility failed to follow prescribed menu guidelines for three residents on puree diets when the incorrect portion size of pureed meatball was served during lunch. Specifically, the facility's recipe for Meatballs/Marinara required serving the meat with a #8 scoop and topping it with 4 oz (1/2 cup) of tomato sauce, totaling 1 cup. However, during an observation of the lunch tray line, staff used a #10 scoop, which is smaller than the required #8 scoop, resulting in residents receiving less than the prescribed portion. A review of the Meal Distribution Report confirmed that the affected residents were on puree diets. The Dietary Supervisor acknowledged during interviews and record review that the cook did not follow the recipe instructions and that the menu was not adhered to as required. This deviation from the prescribed menu and portion sizes was directly observed and confirmed through staff interviews and documentation review.
Failure to Prepare Pureed Diets to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed diets were prepared according to the established recipe for three residents who required a pureed diet. During meal preparation, staff placed six servings of cooked chicken in a food processor, added some chicken broth, and blended the mixture, but did not check the consistency before serving. Upon inspection, the pureed lemon herb chicken served was found to be crumbly, not smooth or lump-free, and did not resemble the required pudding-like consistency. The Dietary Services Supervisor confirmed that the consistency was not appropriate for a pureed diet. A review of the facility's recipe and dietary guidelines indicated that pureed foods should be processed to a fine texture and mixed with a slurry to achieve a smooth, lump-free, pudding-like consistency, suitable for residents with dysphagia who require no biting or chewing. The Registered Dietician confirmed that the recipe was not followed for the residents on a pureed diet. The deficiency was identified through observation, interview, and record review, specifically affecting three medically compromised residents who were prescribed a pureed diet.
Failure to Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit discharge Minimum Data Set (MDS) assessments for two residents, which is a requirement according to federal and state submission timeframes. The facility's policy, dated July 2017, mandates that resident assessments be conducted and submitted in accordance with the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that discharge assessments are required upon a resident's discharge from the facility. Resident #16 was admitted on December 12, 2023, and discharged on January 17, 2024. The discharge MDS, with an Assessment Reference Date (ARD) of January 17, 2024, was not transmitted within the required timeframe. Similarly, Resident #40 was admitted on January 10, 2024, and discharged on January 3, 2024, but the discharge MDS with an ARD of January 30, 2024, was also not transmitted. Interviews with the MDS Nurse, Director of Nursing, and the Administrator confirmed that the MDS assessments were not submitted in a timely manner as per the guidelines.
Failure to Monitor and Document Nebulizer Treatment
Penalty
Summary
The facility failed to conduct a proper assessment and monitoring of a nebulizer treatment for a resident with a history of acute respiratory failure with hypoxia, chronic pulmonary edema, and acute on chronic congestive heart failure. The facility's policy required documentation of various parameters such as pulse, respiratory rate, and lung sounds before and after treatment, as well as the resident's tolerance to the treatment. However, the resident's medical records, including the medication administration record and treatment administration record, lacked evidence of these assessments and documentation. Observations and interviews revealed that the resident did not receive a complete nebulizer treatment as per protocol. The resident reported that the nurse did not stay in the room during the treatment and did not assess their lung sounds before or after the treatment. Interviews with the nursing staff confirmed that they did not document the necessary assessments, and there was a lack of clarity on where such documentation should occur. The Director of Nursing and the Administrator acknowledged that the assessments should have been conducted and documented according to the facility's protocol.
Failure to Monitor Dialysis Fistula in Resident
Penalty
Summary
The facility failed to adequately monitor the dialysis fistula of a resident with end-stage renal disease who required hemodialysis. The facility's policy on the care of arteriovenous fistulas and grafts emphasized the importance of preventing infection and maintaining patency by keeping the access site clean, checking for signs of infection, and assessing the thrill and bruit of the access site. However, the facility did not have an order to check the thrill and bruit of the resident's dialysis access site, and there was a lack of documentation indicating that these assessments were performed. The resident's Dialysis Communication Reports from multiple dates showed no documentation of the status of the access site, including the presence of redness, edema, or drainage, nor any indication that the thrill and bruit were checked prior to dialysis. Interviews with the resident and several Licensed Vocational Nurses (LVNs) revealed inconsistencies in the performance and documentation of these assessments. The resident reported that staff had never assessed their fistula, while LVNs admitted to forgetting to document the assessments or being unsure of the required orders for dialysis care. The Director of Nursing and the Administrator both stated that the facility's protocol required nurses to assess the access site for thrill and bruit and document their findings on the communication form. Despite this expectation, the documentation was incomplete, and the necessary assessments were not consistently performed or recorded, leading to a deficiency in the care provided to the resident.
Medication Unavailability for Resident with Skin Damage
Penalty
Summary
The facility failed to ensure that ordered medication was available for a resident, identified as Resident #32, who was admitted with a diagnosis of paraplegia and moderate cognitive impairment. The resident had moisture-associated skin damage (MASD) and required nystatin-triamcinolone cream to be applied daily to the coccyx and buttocks. Despite the order being placed on 05/28/2024, the medication was not available from 06/01/2024 to 06/05/2024, as documented in the treatment administration record (TAR) and progress notes. The staff noted that the medication was pending delivery from the pharmacy during this period. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that there was a lack of follow-up with the pharmacy and the physician regarding the unavailability of the medication. LVN #6 admitted to faxing the order but did not follow up over the weekend or on the following Monday and Tuesday. Other staff members, including LVN #1 and LVN #4, stated that they would contact the physician for an alternative if a medication was unavailable. The DON and the Administrator emphasized the importance of notifying the physician and obtaining an alternative if necessary, indicating that the staff should have ensured the medication was received promptly.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to properly store nebulizer equipment for a resident with respiratory care needs, as observed during a survey. The facility's policy on infection prevention for respiratory equipment, revised in November 2011, requires that nebulizer circuits be stored in a plastic bag marked with the date and resident's name, and that tubing and bags be replaced weekly. However, observations on multiple occasions revealed that the resident's nebulizer mask and medication cup were left on the nightstand without being stored in a plastic bag, contrary to the facility's policy. The resident, who was admitted with a history of acute respiratory failure, chronic pulmonary edema, and congestive heart failure, required nebulizer treatments every six hours. Despite this, the nebulizer equipment was consistently found improperly stored, as confirmed by interviews with various staff members, including LVNs, CNAs, the Director of Nursing, and the Administrator. All staff interviewed acknowledged that the equipment should be stored in a plastic bag when not in use, yet the equipment was repeatedly observed left out in the open.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inland Christian Home | 1.4 mi | ★★★★★ | 0 | 0 |
| Ontario Healthcare Center | 2.6 mi | ★★★★★ | 12 | 0 |
| Montclair Manor Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Chino Valley Health Care Cente | 2.9 mi | ★★★★★ | 14 | 0 |
| Community Extended Care Hospital Of Montclair | 3.7 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.