Cycle 1
Health 2025-08-14 · Fire 2025-08-14
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Chino, CA
Trellis Chino
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
5454 Walnut Ave, Chino, CA
(909) 465-0246
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2018-10-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.36
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.50
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.99
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
2.17
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,202
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.92
Baseline 23.17% · Performance 21.07% · Measure score 2.92 · Achievement 0.78 · Improvement 2.92
Healthcare-associated infections
1.18
Baseline 9.12% · Performance 8.42% · Measure score 1.18 · Achievement 0 · Improvement 1.18
Total nurse turnover
5.70
Baseline 77.92% · Performance 45.00% · Measure score 5.70 · Achievement 4.57 · Improvement 5.70
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 2.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 510 · Observed rate 10.39% · Lower 95% interval 8.83% |
| Discharge to community | 60.93% |
50.57%
10.4 pts better
|
Better than the National Rate · Eligible stays 578 · Observed rate 53.11% · Lower 95% interval 57.22% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 99.73% |
95.27%
4.5 pts better
|
Numerator 364 · Denominator 365 |
| Falls with major injury | 0.27% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 365 |
| Discharge self-care score | 78.57% |
53.69%
24.9 pts better
|
Numerator 176 · Denominator 224 |
| Discharge mobility score | 63.84% |
50.94%
12.9 pts better
|
Numerator 143 · Denominator 224 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 365 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.42% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 355 · Observed rate 9.3% · Lower 95% interval 6.78% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 150 |
| Staff flu vaccination coverage | 65.1% |
42%
23.1 pts better
|
Numerator 125 · Denominator 192 |
| Discharge function score | 70.54% |
56.45%
14.1 pts better
|
Numerator 158 · Denominator 224 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 138 · Denominator 138 |
| Transfer of health information to patient | 98.6% |
96.28%
2.3 pts better
|
Numerator 211 · Denominator 214 |
| Resident COVID-19 vaccinations up to date | 86.91% |
25.2%
61.7 pts better
|
Numerator 166 · Denominator 191 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
94.0%
5.1 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 99.1% · Q3 100.0% · Q4 98.7% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.2%
6.2 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 4.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 2.5% · Q3 2.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.2%
5.9 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
23.2%
1.9 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 26.4% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-01-06 · Fire 2023-01-06
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-23
F · Potential for more than minimal harm
2025-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-08-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-27
F · Potential for more than minimal harm
2024-06-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-26
E · Potential for more than minimal harm
2024-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-26
C · Minimal harm
2024-06-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-26
D · Potential for more than minimal harm
2023-01-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-30
D · Potential for more than minimal harm
2023-01-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-14
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-14
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-09-05
D · Potential for more than minimal harm
2024-06-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
E · Potential for more than minimal harm
2023-01-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-01-31
D · Potential for more than minimal harm
2023-01-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-31
D · Potential for more than minimal harm
2023-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-31
Penalties and ownership
What sits behind the stars
Ownership
California Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Bay Bridge Capital Partners, LLC
5% Or Greater Indirect Ownership Interest · Organization
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Lords, Trevor
Operational/Managerial Control · Individual
Lords, Trevor
W-2 Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Opco Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Rutherford, Keino
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Inland Christian Home
Ontario, CA
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Ontario Healthcare Center
Ontario, CA
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Montclair Manor Care Center
Montclair, CA
4-star overall rating with 4-star inspections with $2,098 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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