Ellison John Transitional Care: Pain Ignored, Drugs Lost - CA
The resident, identified as Resident 65, pointed to her left foot and told the assistant she had "a lot of pain on the toes" during morning care on February 24. When the nursing assistant tried again to put the sock on, the resident screamed and pulled her left leg away, telling the assistant not to touch her leg.
The nursing assistant continued anyway. She told inspectors she was "trying to put the socks on Resident 65, complete her task, and notify the Charge Nurse after."
The resident had been readmitted to the facility on January 10 with type 2 diabetes, a condition that causes poor wound healing and difficulty controlling blood sugar. She required substantial assistance with most daily activities and had been prescribed Norco, a strong narcotic pain medication, to be given every six hours for moderate to severe pain.
The facility's own pain management policy, last reviewed in December 2024, requires staff to observe residents for behavioral signs of pain including "verbal expressions such as groaning, crying, screaming" and "behavior such as resisting care." Staff are instructed to ask residents about pain and notify nurses immediately.
The nursing assistant admitted to inspectors she should have stopped when the resident first complained of pain. "CNA 1 stated she should have stopped and not try to put the socks on again on Resident 65 and notify the CN to give the resident pain medication," the inspection report states.
Licensed Vocational Nurse 9 confirmed the violation. CNAs "are supposed to stop providing care to residents as soon as the residents verbalized pain accompanied with refusal to be touched during care and notify the CN to address pain and administer pain medication timely," she told inspectors.
The facility's Director of Nursing said the assistant's actions put the resident at risk. "Not recognizing and addressing Resident 65's pain timely placed the resident at risk for continuation to refuse care and/or treatment participation in ADLs or therapy which may lead to decline in function."
But medication problems extended far beyond pain management at the 93534 facility.
Inspectors discovered missing controlled substances in two of four medication carts they examined. On Station 2, they found one missing dose of clonazepam, a seizure medication prescribed for Resident 87. The drug control record showed six doses remaining, but only five were actually in the medication card.
Licensed Vocational Nurse 4 admitted she had given the missing dose around 10 a.m. but forgot to sign it out of the controlled substance log. She was "distracted by other tasks and did not remember to do it when she returned."
"It is important to maintain accountability of controlled substances to prevent diversion or accidental overdose to the resident," she told inspectors. If Resident 87 received clonazepam more often than prescribed, "it could cause medical complications possibly leading to hospitalization."
On Station 3, inspectors found another missing controlled substance. The drug control record for Resident 93's lorazepam showed 12 doses remaining, but the medication card contained only 11. Licensed Vocational Nurse 3 had given the missing dose at 1:07 p.m. but failed to document it.
"Signing the controlled drug record ensures the count is correct to prevent any missing medications and possibly prevent the resident from receiving it more often than necessary," she explained to inspectors. Overdosing Resident 93 with lorazepam "could cause additional drowsiness or other adverse effects which could negatively impact her health or well-being."
The facility's controlled substance policy requires nurses to sign out medications "immediately" after administration. Both nurses violated this requirement.
Another resident waited over four hours for anxiety medication she had requested at 6 a.m. Resident 347, newly admitted on February 21 with generalized anxiety and depression, asked for her prescribed alprazolam at the start of the morning shift. She never received it.
When inspectors found her at 10 a.m., she was lying in bed using her call light. "Oh, there you are, I haven't seen you all morning," she told the nurse who finally responded. "I felt anxious and depressed and did not receive the medication she requested at 6 a.m."
The morning nurse, LVN 6, had told the night nurse, LVN 7, to give the medication. But LVN 7 thought LVN 6 was going to give it. Neither did.
"When Resident 347 requested alprazolam at 6 a.m. and the medication was not administered until after 10 a.m., it was considered a delay in the delivery of the medication which could have resulted in Resident 347 having an anxiety attack with feelings of stress, fear, and impending doom," LVN 7 told inspectors.
The facility's Director of Nursing called the delay unacceptable. "Waiting more than three hours to administer alprazolam to Resident 347 was too long and could have resulted in increased anxiety in the resident affecting their ability to participate in their normal activities of daily living and negatively impact their psychosocial wellbeing."
A third medication failure involved Resident 197, who missed three doses of levothyroxine for hypothyroidism. She told inspectors she had "only received her thyroid medication only two to three times this week" since her February 17 admission.
LVN 1 confirmed the discrepancy when inspectors examined her medication bubble pack. Of 15 doses dispensed by the pharmacy, only 10 had been administered as documented on her medication record. Eight tablets remained in the bubble pack, leaving three unaccounted for.
"When Resident 197's levothyroxine are not administered the resident could have confusion," LVN 1 told inspectors. The Director of Nursing said missing thyroid medication "could affect Resident 197's thyroid functioning."
The facility also failed to respond to consultant pharmacist recommendations dating back to November. The pharmacist had flagged Resident 101's PRN lorazepam prescription, recommending the facility either limit it to 14 days or define a specific length of therapy. No action was taken.
In December, the same pharmacist recommended defining the length of therapy for Resident 101's guaifenesin cough medication. Again, the facility failed to respond.
These medication review violations increased the risk that Resident 101 "could have experienced adverse effects related to their medication therapy possibly leading to impairment or decline in her mental or physical condition," according to the inspection report.
The facility's medication administration policy, last reviewed in December 2025, states its purpose is "to provide employees with guidelines for the safe and timely administration of medications per physician orders. Medications must be administered in accordance with the orders."
But Resident 65 still screams when staff try to dress her feet.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE ELLISON JOHN TRANSITIONAL CARE CENTER in LANCASTER, CA was cited for violations during a health inspection on February 28, 2025.
When the nursing assistant tried again to put the sock on, the resident screamed and pulled her left leg away, telling the assistant not to touch her leg.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.