The facility also repeatedly gave insulin injections to three diabetic residents in the same body locations instead of rotating sites, creating risks of excessive bruising and abnormal fat distribution under the skin.
Federal inspectors found the 43830 10th Street West facility failed to follow basic medication safety protocols during a February 28 inspection, documenting violations that put residents at risk of drowsiness, dizziness, falls, and other adverse effects.
Psychiatric Medications Left Unchanged Despite Orders
Resident 1, admitted with major depressive disorder and anxiety, was prescribed 50 milligrams of sertraline daily and 0.5 milligrams of lorazepam for anxiety in July 2024. A consultant pharmacist recommended reducing both medications in January 2025, and the psychiatric nurse practitioner agreed to decrease sertraline to 25 milligrams and discontinue lorazepam entirely.
The nurse practitioner documented the plan in progress notes dated February 24: "Decrease sertraline 25 mg oral tablet QD. Discontinue lorazepam tablet 0.5 mg QD."
But the facility never made the changes.
Director of Nursing confirmed to inspectors that despite the pharmacist's recommendations and the nurse practitioner's documented plan, "the facility failed to implement the changes in dose and Resident 1 was still receiving 50 mg of sertraline and still had an active order for lorazepam."
Nobody from the facility followed up with the nurse practitioner to obtain the necessary new orders.
Resident 71 faced identical problems. The consultant pharmacist recommended reducing her amitriptyline dose from 50 milligrams to 25 milligrams at bedtime. The nurse practitioner agreed and documented the plan on February 24, but staff continued giving the higher dose.
The Director of Nursing acknowledged the failures increased risks that both residents "may have experienced adverse effects including drowsiness, dizziness, dry mouth, or fall with injury possibly leading to a decline in their functional status or quality of life."
Anxiety Medication Continued for Nine Months Without Limits
Resident 101 received lorazepam as needed for anxiety from May 2024 through February 2025 without any time limits, violating the facility's own 14-day policy for psychiatric medications.
The consultant pharmacist warned in November 2024 that the facility must limit lorazepam to 14 days or document a longer duration with clinical rationale. The facility's response on December 17: "no new orders."
The medication continued for nine months without proper oversight.
The Director of Nursing explained that unlimited psychiatric medications create risks because "the reason for using PRN medications may change with the passage of time and must be limited so they can be periodically reevaluated to determine if the resident still has need for them."
Antipsychotic Given Without Clear Medical Reason
Resident 68, who has dementia, received quetiapine for "adjunct treatment of depression manifested by physical aggression" between January 22 and January 29. But her clinical record contained no documentation supporting the need for combining an antipsychotic with an antidepressant.
Staff monitored for verbal aggression instead of the physical aggression listed in the medication order.
The psychiatric nurse practitioner told inspectors by phone he "was not aware of Resident 68 needing quetiapine as adjunct therapy" and that "this medication should not have been continued upon her admission to the facility as it was being given for agitation or anxiety during her hospital stay."
He discontinued the medication because continuing it "put this resident at risk for sedation, dizziness, drowsiness, increased risk of fall with injury, and unexplained death or stroke which outweighed any benefit she may have received from it."
Two Antidepressants Prescribed Simultaneously
Resident 347 received both sertraline and escitalopram simultaneously without documented medical justification. Both medications are in the same class of antidepressants and are rarely used together.
The psychiatric nurse practitioner told inspectors the combination was inappropriate and resulted from a communication breakdown. He had given verbal orders to discontinue sertraline when starting escitalopram on February 24, but staff apparently never received the message.
"Using them together could cause additional adverse effects related to their use which could decrease Resident 347's quality of life," the nurse practitioner said.
Insulin and Blood Thinner Injections in Same Locations
Three residents receiving subcutaneous injections faced a different medication safety problem. Staff repeatedly gave insulin and heparin shots in the same body locations instead of rotating injection sites as required.
Residents 65, 29, and 52 all received injections without proper site rotation, creating risks of excessive bruising, abnormal fat distribution, and protein buildup in the skin.
Medical standards require rotating injection sites to prevent tissue damage and ensure proper medication absorption.
Missing Thyroid Medication Doses
Resident 197 missed three doses of levothyroxine, a thyroid hormone replacement medication that must be taken consistently to prevent heart problems and cognitive impairment.
The facility provided no explanation for the missed doses.
Cough Medicine Without Time Limits
Beyond psychiatric medications, the facility failed to limit other drugs according to its own policies. Resident 101 received guaifenesin cough medicine without a stop date, despite facility policy limiting cough and cold preparations to 10 days.
A consultant pharmacist recommended adding a time limit in December 2024, but the facility showed "no apparent response."
The Director of Nursing acknowledged that unlimited cough medicine created risks because medications "may change with the passage of time and must be limited so they can be periodically reevaluated."
Federal inspectors classified all violations as causing minimal harm or potential for actual harm, affecting some or few residents. The facility's systematic failure to implement medication changes recommended by its own consultant pharmacist and psychiatric nurse practitioner revealed gaps in communication and oversight that left multiple residents on inappropriate medication regimens for months.
The Ellison John Transitional Care Center operates as a transitional care facility in Lancaster's Antelope Valley, serving residents who require skilled nursing care and rehabilitation services before returning home or moving to long-term care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Ellison John Transitional Care Center from 2025-02-28 including all violations, facility responses, and corrective action plans.
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