Ellison John Transitional: Medication Left Unattended - CA
The September incident at The Ellison John Transitional Care Center involved a 73-year-old patient admitted three days earlier with acute respiratory failure, diabetes, and an enlarged prostate. The patient had been prescribed polyethylene glycol powder mixed with eight ounces of water once daily for bowel management.
On September 10 at 10:30 a.m., inspectors watched Licensed Vocational Nurse 2 leave the patient's room and walk to the nurse station. She left the medication mixture sitting on the bedside table.
The nurse returned to stand at the doorway. She told the inspector she had given all the patient's scheduled medications and was going to document them as administered.
When the inspector asked for clarification about whether all scheduled medications had been given, the nurse looked into the room and noticed the water mixture still sitting there.
"She forgot to give the resident's water mixed with polyethylene glycol 3350 powder," the inspection report states.
The nurse admitted she shouldn't leave medications unattended. She told inspectors that leaving medications accessible had the potential for other residents to take them, or for the patient to not receive the medication, which could result in discomfort and constipation.
Later that afternoon, Registered Nurse 1 confirmed the medication should not have been left unattended. The supervisor told inspectors that other residents could potentially drink the patient's medication from the bedside table, thinking it was regular water.
The registered nurse said the facility failed to ensure the patient's medication wasn't left unattended and failed to ensure the patient received all scheduled medications before the nurse left the room.
The patient had been admitted on September 8 with serious breathing problems requiring respiratory support. Medical records from September 9 indicated he had the mental capacity to understand and make decisions about his care.
Polyethylene glycol is commonly prescribed to prevent constipation, particularly important for patients with limited mobility or those taking medications that can cause bowel problems. The powder is typically mixed with water or juice to make it easier to consume.
The facility's own medication administration policy, last reviewed in December 2024, requires employees to follow guidelines for safe and timely medication administration per physician orders. The policy specifically mentions a "pour, pass, chart" standard of practice after verifying both the resident and scheduled medication.
Federal inspectors documented the violation under regulations requiring drugs and biologicals to be stored safely and securely. The inspection found the facility failed to ensure safe pharmaceutical services for the patient by leaving his medication unattended at bedside.
The deficient practice created potential for medication errors and could have led to the patient's discomfort, inspectors determined. While classified as causing minimal harm with few residents affected, the violation highlighted gaps in basic medication safety protocols.
The incident occurred during the patient's first week at the transitional care facility, when establishing proper medication routines would be particularly important for someone managing multiple serious health conditions requiring careful monitoring and treatment compliance.
Federal regulations mandate that all medications be properly secured and administered according to professional standards to prevent errors, contamination, or unauthorized access by other residents who might consume medications not prescribed for them.
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 2025-09-11 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 21, 2026 · Our methodology
THE ELLISON JOHN TRANSITIONAL CARE CENTER in LANCASTER, CA was cited for violations during a health inspection on September 11, 2025.
The patient had been prescribed polyethylene glycol powder mixed with eight ounces of water once daily for bowel management.
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.