Trellis Paradise

In the surveyor’s words

From the most serious findings on record at Trellis Paradise, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Mar 26, 2025

  Based 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. Findings include: On 03/26/2025 at 8:21 AM, a treatment cart was left outside of the nourishment room across from the clean linen room, unlocked and unattended. The drawers were easily accessible to a resident or visitor walking by the cart. The contents inside the treatment cart were scissors, various ointments, creams and various sized dressings. […]

• No harm, potential for more than minimal, patternF694Sep 29, 2023

  Based 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). […]

• No harm, potential for more than minimal, isolatedF627Jul 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF658Jul 9, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure documentation of care was accurate and truthful as outlined in the Documentation Guidelines of the American Nurses Association for 1 of 36 sampled residents (Resident 101). The deficient practice placed residents at risk for negative outcomes.Findings include:Resident 101 (R101) was admitted on [DATE], with diagnoses including osteomyelitis of ankle and foot. A hospital Discharge summary dated [DATE], revealed R101 underwent surgery for an infected right ankle on 06/18/2026 and a PICC line was placed on 06/19/2026 for a six-week IV antibiotic course.A nursing admission assessment dated [DATE], revealed R101 was admitted to the facility with a right upper arm PICC line.The admission minimum… […]

• No harm, potential for more than minimal, isolatedF676Jul 9, 2026

  Based on observation, interview, record review and document review, the facility failed to ensure residents received necessary Activities of Daily Living (ADL) services to maintain the highest practicable physical, mental, and psychosocial well being for 1 of 36 sampled residents (Resident 35). The deficient practice placed the resident at risk not receiving needed services to support daily functioning. Findings include:Resident 35 (R35) was admitted on [DATE] with diagnoses including surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker, acute chronic diastolic (congestive) heart failure, and cellulitis of left lower limb.On 07/07/2026 at 9:35 AM, R35's feet were noted to be dry, with visible flaking and shedding of the skin. […]