LANCASTER, CA - Federal inspectors documented systematic medication administration failures at The Ellison John Transitional Care Center during a February 2025 inspection, citing the facility for multiple violations that put vulnerable residents at risk.
Widespread Injection Site Rotation Failures
The most significant violations involved improper administration of injectable medications affecting at least four residents with diabetes and other serious conditions. Inspectors found that nursing staff repeatedly failed to rotate injection sites for insulin and blood-thinning medications, despite specific physician orders and manufacturer guidelines requiring this practice.
Resident 65, who has Type 2 diabetes and requires insulin injections, received multiple doses in the same abdominal location over a two-week period in February. According to inspection records, insulin was administered in the left lower quadrant of the abdomen on February 2, 3, 8, and 15, with minimal variation. The resident's physician orders specifically required rotation of injection sites.
Resident 29, receiving both insulin and heparin injections, experienced similar failures. The resident received multiple doses of blood-thinning medication in the same abdominal area on consecutive days, violating both physician orders and professional standards.
Resident 52, requiring twice-daily insulin injections, also had doses administered repeatedly in the same locations rather than being properly rotated across different body areas.
Medical Consequences of Improper Injection Techniques
The failure to rotate injection sites creates serious health risks for residents. When medications like insulin are repeatedly injected in the same location, lipodystrophy can develop - a condition where fat tissue either builds up or breaks down abnormally. This creates visible lumps, pits, or hardened areas in the skin that can significantly impair medication absorption.
The Director of Nursing acknowledged during the inspection that not rotating administration sites "can affect absorption of the insulin" and "is a medication error due to not following the MD orders, manufacturer's guideline, and professional standards of practice."
Heparin injection site rotation is equally critical. The facility's own policies and federal guidelines specify that different sites must be used "to prevent the development of massive hematoma" - large, dangerous blood clots under the skin.
Missed Critical Medications
Beyond injection technique failures, inspectors documented that Resident 197 missed three doses of thyroid medication out of 13 scheduled doses between February 17-28, 2025. The resident, who has hypothyroidism requiring daily thyroid replacement therapy, told inspectors she had "only received her thyroid medication only two to three times this week."
Thyroid medications must be taken consistently to maintain proper hormone levels. Missing doses can lead to fatigue, cognitive difficulties, and other serious health complications. The licensed vocational nurse acknowledged that when the resident's thyroid medication "are not administered the resident could have confusion."
Systemic Policy Failures
The medication errors appear to reflect broader systemic issues rather than isolated incidents. The facility's own policies require injection site rotation "to reduce the risk of damaging the skin tissue," yet multiple staff members failed to follow these protocols across different units and shifts.
Licensed Vocational Nurse 3 told inspectors that "insulin administration sites should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident's skin." Despite this knowledge, the practice continued.
Additional Safety Concerns
The inspection revealed several other violations affecting resident care:
Dental Care Delays: Resident 89 requested routine dental care three months prior to the inspection but never received an appointment. The facility failed to coordinate alternative arrangements when the resident's insurance denied coverage for on-site services.
Dietary Preference Violations: Resident 59 was served fish during lunch on February 28, despite documented dietary preferences indicating the resident dislikes fish. The resident's meal ticket clearly noted this preference, but multiple staff members failed to notice before serving the meal.
Food Safety Issues: Kitchen staff stored dented cans alongside undamaged inventory and failed to date an opened package of graham crackers, violating food safety protocols designed to prevent contamination.
Infection Control Failures: Staff placed an oxygen cannula from the floor directly onto a resident's bed without replacement, and failed to follow Enhanced Barrier Precautions for a resident with an indwelling medical device.
Professional Standards and Best Practices
Medicare and Medicaid regulations require nursing homes to ensure medications are administered according to physician orders, manufacturer specifications, and accepted professional standards. The facility's own policies acknowledge these requirements but enforcement appeared inconsistent.
Proper injection technique involves rotating sites by at least 1.5 centimeters from previous locations and using different body areas - abdomen, arms, and thighs - to prevent tissue damage. Insulin manufacturers specifically warn against injecting "where the skin has pits, is thickened, or has lumps" or "where the skin is tender, bruised, scaly or hard."
For residents requiring multiple daily injections, systematic rotation becomes critical to maintaining adequate medication absorption and preventing complications that could require additional medical intervention.
Facility Response and Oversight
The inspection occurred February 28, 2025, as part of routine federal oversight of nursing home care quality. The Ellison John Transitional Care Center is required to submit a plan of correction addressing each identified deficiency.
The facility's Director of Nursing acknowledged the medication errors during interviews with inspectors and confirmed that proper protocols were not followed. The violations were classified as causing "minimal harm or potential for actual harm" but affecting "some" residents in multiple categories.
The 150-bed facility serves medically complex residents requiring skilled nursing care, many with conditions like diabetes that require precise medication management. Federal regulations require facilities to maintain adequate staffing levels and training to ensure safe medication administration practices.
The inspection findings highlight ongoing challenges in nursing home medication management and the need for consistent staff training and supervision to prevent potentially serious complications for vulnerable residents requiring complex medical 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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