The Ellison John Transitional Care Center

F-F658

Findings:

a. During a review of Resident 65 ' s Admission Record, the Admission Record indicated the facility originally admitted the resident on 2/8/2021 and readmitted the resident on 1/10/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and generalized muscle weakness.

During a review of Resident 65 ' s History and Physical (H&P) dated 1/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions.

During a review of Resident 65 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/17/2025, the MDS indicated Resident 65 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with toileting hygiene, bathing, and lower body dressing; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 65 received insulin.

During a review of Resident 65 ' s care plan (CP) titled Risk for hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar) relate to diagnosis of DM 2 initiated on 1/13/2025 and last revised

on 1/24/2025, the CP indicated to administer insulin lispro injection as ordered per sliding scale as one of the interventions to minimize complications related to DM 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 65 ' s Order Summary Report, the Order Summary Report indicated the following physician ' s orders 1/28/2025: Level of Harm - Minimal harm or potential for actual harm Insulin lispro injection solution (a short acting insulin) 100 unit per milliliter (unit/ml) inject subcutaneously

before meals and at bedtime for DM 2. Residents Affected - Some Fingerstick blood sugar (FSBS - most common type of blood sugar monitoring) using lancets (a small needle) and test strips. Rotate injection site. Inject as per sliding scale (increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 units; if BS less than (<) 70 and awake give juice; if unresponsive, give Glucagon (a hormone that raises blood sugar) 1 milligram (mg - a unit of measurement) intramuscularly (IM - inject into the muscle) and notify physician (MD); 150 - 199 = 4 units; 200 - 249 = 8 units; 250 - 299 = 12 units; 300 - 349 = 16 units; 350 plus = 20 units and notify MD.

During a concurrent interview and record review on 2/27/2025 at 12:22 p.m., Resident 65 ' s physician ' s orders, Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) Location of Administration Report for 2/2025 was reviewed with Licensed Vocational Nurse 3 (LVN 3). LVN 3 stated Resident 65 had a physician ' s order for insulin lispro which was administered as follows:

Insulin lispro injection solution 100 unit/ml:

2/02/25 10:19 p.m. subcutaneously abdomen - left lower quadrant (LLQ)

2/03/25 4:29 p.m. subcutaneously abdomen - LLQ

2/03/25 11:31 subcutaneously abdomen - LLQ

2/06/25 4:54 p.m. subcutaneously abdomen - right lower quadrant (RLQ)

2/06/25 8:02 p.m. subcutaneously abdomen - RLQ

2/08/25 12:25 p.m. subcutaneously abdomen - LLQ

2/08/25 4:08 p.m. subcutaneously abdomen - LLQ

2/12/25 8:26 p.m. subcutaneously abdomen - RLQ

2/13/25 5:59 a.m. subcutaneously abdomen - RLQ

2/15/25 11:43 a.m. subcutaneously abdomen - LLQ

2/15/25 5:26 p.m. subcutaneously abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 LVN 3 stated insulin administration sites should be rotated per standards of practice, manufacturer ' s guidelines, and according to physician ' s orders. LVN 3 stated Resident 65 ' s MAR indicated the insulin Level of Harm - Minimal harm or administration sites were not rotated and there was a physician ' s order to rotate injection sites. LVN 3 potential for actual harm stated Resident 65 ' s insulin administration sites should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident ' s skin. Residents Affected - Some

During an interview on 2/28/025 at 1 p.m. Resident 65 ' s physician ' s orders, MAR Location of Administration Report for 2/2025 was reviewed with the Director of Nursing (DON). The DON stated the location of administration sites for Resident 65 ' s insulin was not rotated. The DON stated the charge nurses (CN) are required to rotate the insulin administration sites according to standards of practice, as indicated in

the manufacturer ' s guideline, and physician ' s order. The DON stated Resident 65 had a physician ' s order to rotate injection sites. The DON stated Resident 65 ' s administration sites for insulin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. The DON stated not rotating the administration sites of insulin can be considered a medication error due to not following the MD orders, manufacturer ' s guideline, and professional standards of practice.

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b. During a review of Resident 29 ' s Admission Record, the Admission Record indicated the facility admitted

the resident on 1/22/2025, with diagnoses including type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar [glucose] levels to be abnormally high), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls).

During a review of Resident 29 ' s History and Physical (H&P), dated 1/23/2025, the H&P indicated the resident was on DVT (DVT, a blood clot in a vein deep in the body, usually in the leg) prophylaxis (an attempt to prevent disease) heparin subcutaneous (sq, beneath, or under, all the layers of the skin) and the resident had the ability to make self-understood and understand others.

During a review of Resident 29 ' s Minimum Data Set (MDS, a resident assessment tool), dated 1/29/2025,

the MDS indicated the resident had the ability to make self-understood and to understand others and had intact cognition (person's cognitive abilities like memory, understanding, problem-solving etc. are working usually in all fundamental ways). The MDS indicated the resident was on an anticoagulant and hypoglycemic medications (a class of drugs that help lower blood sugar levels).

During a review of Resident 29 ' s Order Summary Report, the Order Summary Report indicated an order as follows:

1/22/2025 Heparin Sodium (Porcine) Injection Solution 5000 unit per milliliters (unit [s an amount approximately equivalent to 0.002 mg of pure heparin]/ml [ a unit of volume]) (Heparin Sodium (Porcine)). Inject 1 milliliter subcutaneously three times a day for DVT prophylaxis. Rotate injection sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 1/22/2025 Heparin: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (small red or purple spots on the skin or inside the mouth that are caused by broken blood Level of Harm - Minimal harm or vessels), internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by (+)YES or(-)NO. Notify MD if potential for actual harm (+). Every shift.

Residents Affected - Some 1/27/2024 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal.): if 70 - 149 = 0, If blood sugar (BS) is less than 70 & awake, given orally (PO) juice. If unresponsive give Glucagon (a hormone that raises blood sugar [glucose]) 1 milligram (mg, a unit of weight) intramuscular (IM, within or into the muscle), notify MD. 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350+ = 6 units Notify MD, subcutaneously before meals and at bedtime for Type 2 diabetes mellitus rotate injection site.

During a review of Resident 29 ' s Location of Administration Report of Humulin R and Heparin Sodium for 1/2025 to 2/2025, the Location of Administration Report indicated Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered subcutaneously on:

1/24/2025 at 9:03 p.m. on the abdomen - Left Lower Quadrant (LLQ)

1/25/2025 at 6:37 a.m. on the abdomen - LLQ

And Humulin R Injection Solution 100 unit/ml was administered subcutaneously on:

1/29/2025 at 5:33 a.m. on the abdomen - LLQ

1/29/2025 at 12:23 p.m. on the abdomen - LLQ

2/14/2025 at 8:22 p.m. on the abdomen - Left Upper Quadrant (LUQ)

2/15/2025 at 8:46 p.m. on the abdomen - LUQ

During a concurrent interview and record review on 2/26/2025, at 8:47 a.m., with Registered Nurse (RN) 1, Resident 29 ' s Location of Administration Report for Humulin R and Heparin Sodium for 1/2025 to 2/2025 were reviewed. RN 1 stated there were multiple instances where the licensed staff did not rotate the subcutaneous administration of heparin and Humulin R on the resident. RN 1 stated it was important to rotate heparin and Humulin R administration sites to prevent excessive bruising and lipodystrophy on residents. RN 1 stated not rotating Humulin R and Heparin Sodium subcutaneous administration sites is a medication error.

During an interview on 2/28/2025, at 9:04 a.m., with the Director of Nursing (DON), the DON stated the licensed staff should have rotated Resident 29 ' s Humulin R and heparin subcutaneous administration sites to prevent adipose tissue (a connective tissue that extends throughout your body) buildup on the frequented site, discoloration, and hardening of the skin which can affect absorption of the medication. The DON added there was no reason for the licensed staff to repeat administration sites as it appears on the electronic healthcare record where the last subcutaneous administration of heparin and Humulin R was given. The DON stated not rotating Humulin R and Heparin Sodium subcutaneous administration sites is a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 c. During a review of Resident 52 ' s Admission Record, the Admission Record indicated the facility admitted

the resident on 6/6/2024, with diagnoses including type 2 diabetes mellitus, gastro-esophageal reflux disease Level of Harm - Minimal harm or (GERD, a condition where stomach acid flows into the esophagus), and dysphagia (swallowing difficulties). potential for actual harm

During a review of Resident 52 ' s H&P, dated 6/21/2024, the H&P indicated the resident did not have the Residents Affected - Some capacity to understand and make decisions.

During a review of Resident 52 ' s MDS, dated [DATE REDACTED], the MDS indicated the resident rarely to never had

the ability to make self-understood and understand others and had severely impaired cognitive skills (a condition that makes it difficult for someone to think, learn, remember, and make decisions) for daily decision making. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.

During a review of Resident 52 ' s Order Summary Report, dated 2/22/2025, the Order Summary Report indicated an order of Insulin NPH (Human) (Isophane) Subcutaneous Suspension Pen-injector 100 unit/ml (Insulin NPH [Human] [Isophane]). Inject 18 units subcutaneously two times a day for diabetes/hyperglycemia (a condition in which there is too much glucose in the blood, also known as high blood sugar). Rotate injection sites, hold for blood sugar (BS) less than (<) 100.

During a review of Resident 52 ' s Location of Administration Report of Insulin NPH (Isophane) for 1/2025 to 2/2025, the Location of Administration Report indicated Insulin NPH (Isophane) Subcutaneous Suspension Pen-Injector 100 unit/ml was administered on:

1/5/2025 at 5:10 a.m. on the abdomen - LLQ

1/5/2025 at 6:04 p.m. on the abdomen - LLQ

1/19/2025 at 5:11 a.m. on the abdomen - LLQ

1/19/2025 at 5:05 p.m. on the abdomen - LLQ

2/7/2025 at 5:08 p.m. on the abdomen - Right Lower Quadrant (RLQ)

2/8/2025 at 6:55 a.m. on the abdomen - RLQ

During a concurrent interview and record review on 2/26/2025, at 8:55 a.m., with RN 1, Resident 52 ' s Location of Administration Report for Insulin NPH (Isophane) for 1/2025 to 2/2025. RN 1 stated there were multiple instances where the licensed staff did not rotate the subcutaneous administration of Insulin NPH (Isophane) on the resident. RN 1 stated it was important to rotate Insulin NPH (Isophane) administration sites to prevent excessive bruising and lipodystrophy on residents. RN 1 stated not rotating Insulin NPH (Isophane) subcutaneous administration sites is a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 2/28/2025, at 9:04 a.m., with the DON, the DON stated the licensed staff should have rotated Resident 52 ' s Insulin NPH (Isophane) subcutaneous administration sites to prevent adipose tissue Level of Harm - Minimal harm or buildup on the frequented site, discoloration, and hardening of the skin which can affect absorption of the potential for actual harm medication. The DON added there was no reason for the licensed staff to repeat administration sites as it appears on the electronic healthcare record where the last subcutaneous administration of Insulin NPH Residents Affected - Some (Isophane) was given. The DON stated not rotating Insulin NPH (Isophane) subcutaneous administration sites is a medication error.

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d. During a review of Resident 197 ' s Admission Record, the Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses including presence of left artificial hip joint, hypertensive heart disease (high blood pressure), and hypothyroidism.

During a review of Resident 197 ' s physician order, dated 2/17/2025, the physician order indicated levothyroxine sodium oral tablet 75 micrograms (mcg-a unit of measurement) give one tablet by mouth one time a day for hypothyroidism.

During a review of Resident 197 ' s H&P, dated 2/18/2025, the H & P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 197 ' s Care Plan Report, dated 2/18/2025, the Care Plan Report indicated the care plan focus indicated the resident has hypothyroidism and required daily thyroid replacement. The Care Plan Report interventions included to give thyroid replacement therapy as ordered and to monitor or document for side effects and effectiveness done by the licensed nurses.

During an interview on 2/24/2025 at 10:18 a.m. with Resident 197, Resident 197 stated she has been here since 2/17/2025 and she has only received her thyroid medication only two to three times this week. Resident 197 stated she has not received her thyroid medication this morning.

During a concurrent observation and interview on 2/27/2025 at 6:23 a.m. with Licensed Vocational Nurse (LVN) 1 in Nursing Station 1, Resident 197 ' s levothyroxine bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles (or blisters). Each pack is secured by a strong, paper-backed foil that protects the pills until dispensed) inside the medication cart. LVN 1 stated the levothyroxine 75 mcg tablet bubble pack was filled on 2/17/2025 with a total of five (5) doses/tablets which were administered. LVN 1 stated he has not administered today ' s dose yet because resident prefers to receive it at 7 a.m.

During a concurrent interview and record review on 2/28/2025 at 7:17 a.m. with LVN 1, Resident 197 ' s Medication Administration Record (MAR), dated 2/1/2025 - 2/28/2025 was reviewed. The MAR indicated, a total of 10 doses of levothyroxine were administered from 2/18/2025 to 2/28/2025. LVN 1 stated, there was a total of 15 doses in the bubble pack and 8 tablets were still in the bubble pack. LVN 1 stated there were three (3) tablets that were not administered. LVN 1 stated when Resident 197 ' s levothyroxine are not administered the resident could have confusion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 2/28/2025 at 8:47 a.m. with the Director of Nursing (DON), the DON stated Resident 197 ' s medication should be administered as ordered and it is given to treat specific diseases and be Level of Harm - Minimal harm or monitored. The DON stated when medication is not administered it could affect Resident 197 ' s thyroid potential for actual harm functioning. The DON stated LVN 1 should call the doctor and family/representative to inform them about what happened. The DON stated if the doctor will order a thyroid test the licensed nurse will carry out the Residents Affected - Some order and monitor the resident for any changes. The DON stated this is a medication error and entails a change in condition.

During a review of the facility provided undated manufacturer ' s guideline for insulin lispro, the manufacturer ' s guideline indicated:

- Change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

- Do not inject where the skin has pits, is thickened, or has lumps.

- Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin.

- Choose your injection site: insulin lispro is injected under the skin of your stomach area, buttocks, upper legs or upper arms.

During a review of the facility's recent policy and procedure titled Medication Errors, last reviewed on 12/3/2024, the P&P indicated Medication error: The observed or identified preparation or administration of medications or biologicals which is not in accordance with:

a. The prescriber's order.

b. Manufacturer's specifications regarding the preparation and administration of the medication or biological; or

c. Accepted professional standards and principles which apply to professionals providing services.

d. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.

During a review of the facility's recent policy and procedure (P&P) titled Medication Errors, last reviewed on 12/3/2024, the P&P indicated a medication error is the observed or identified preparation or administration of medications or biologicals which is not in accordance with:

a. The prescriber's order.

b. Manufacturer's specifications regarding the preparation and administration of the medication or biological; or

c. Accepted professional standards and principles which apply to professionals providing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 d. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's recent policy and procedure (P&P) titled Insulin Administration, last reviewed

on 12/3/2024, the P&P indicated the injection sites should be rotated to reduce the risk of damaging the skin Residents Affected - Some tissue.

During a review of the facility-provided Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982, the Highlights of Prescribing Information indicated subcutaneous injection: inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Highlights of prescribing Information on the use of Heparin Sodium Injection, USP for intravenous or subcutaneous use, with initial U.S. approval in 2009, the Highlights of Prescribing Information indicated under method of administration for deep subcutaneous (intrafat) injection, a different site should be used for each injection to prevent the development of massive hematoma.

During a review of the facility-provided Consumer Information on the use of Humulin N vials insulin isophane, human biosynthetic (rDNA origin), suspension for injection, 100 units/mL, the Consumer Information indicated to avoid tissue damage (skin thinning, skin thickening, or skin lumps). always change the site for each injection by at least 1.5 cm (0.5 inches) from the previous site, rotating sites of the body so that the same site is not used more that approximately once a month. Do not inject into pits (depressions), thickened skin or lumps.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on interview and record review, the facility failed to promptly provide dental services for one out of Residents Affected - Few three sampled residents (Residents 89) investigated under dental services by failing to schedule a dental appointment for Resident 89.

This deficient practice placed Resident 89 at risk for a delay in the necessary dental and services the resident needs which result in the inability to pain, effectively chew foods, weight changes, lack of energy and loss of muscle mass.

Findings:

During a review of Resident 89 ' s Admission Record, the Admission Record indicated the facility originally admitted the resident on 1/16/2024 and readmitted the resident in the facility on 11/18/2024 with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting

in painful deformity and immobility) multiple sites, age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and generalized muscle weakness.

During a review of Resident 89 ' s History and Physical (H&P), dated 11/19/2024, the H&P indicated Resident 89 had fluctuating capacity to understand and make decisions.

During a review of Resident 89 ' s Minimum Data Set (MDS - a resident assessment tool), dated 12/30/2024,

the MDS indicated Resident 83 had intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial/moderated assistance to substantial/maximal assistance from staff with all other activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).

During a review of Resident 89 ' s Order Summary Report, dated 11/18/2024, the Order Summary Report indicated a physician ' s order for social services to arrange for dental consult as needed.

During an interview, on 2/24/2025, at 10:52 a.m., inside Resident 89 ' s room, Resident 89 stated that she had requested routine dental care from the social services department about three months ago. Resident 89 stated she had mentioned during one of the meetings and did not hear back from the social services department. Resident 89 was unable to remember the last time she was seen by the dentist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 During an interview, on 2/25/2025, at 1:20 p.m., with Social Services Assistant (SSA) 1, SSA 1 stated the dentist comes to the facility on e (1) to two (2) times a month and residents are seen based on the current list Level of Harm - Minimal harm or of residents provided by the facility prior to each visit to determine which residents were not seen yet. SSA 1 potential for actual harm stated some residents are not seen by the dentist due to resident insurance not paying for services to be provided in the facility. SSA 1 stated the social services department makes arrangements for resident ' s Residents Affected - Few dental appointments if not covered by the insurance in the facility. SSA 1 stated Resident 89 ' s insurance denied the authorization and they have not arranged her dental appointment. SSA 1 stated they should have arranged for Resident 89 ' s dental appointment as previously requested and update the resident as needed so Resident 89 would be aware of the plan for her dental care. SSA 1 stated she spoke with Resident 89 in

the afternoon of 2/24/2025 about her dental appointment and did not document her conversation with the resident.

During a concurrent interview and record review, on 2/28/2025, at 9:09 a.m., the with Social Services Director (SSD), Resident 89 ' s social services notes and physician orders were reviewed. The SSD confirmed and stated there was a physician ' s order for dental consultation as needed and there was no documentation of the conversation by the social services department regarding dental care or appointments with Resident 89. The SSD stated if a resident ' s insurance does not cover dental services in the facility, the case manager will obtain authorization from the resident ' s insurance, and the social services department will make an appointment and arrange transportation to and from a dental services clinic. The SSD stated SSA 1 should have notified the case manager to obtain authorization for Resident 89 ' s needed dental services so Resident 89 ' s request for dental services can be arranged timely. The SSD stated not meeting Resident 89 ' s dental services needs placed Resident 89 at risk for a delay in the necessary care and services the resident needed, which may lead to pain, difficulty chewing, and being unable to eat.

During a review of the facility ' s policy and procedure (P&P) titled, Dental Services, last reviewed 12/3/2024,

the P&P indicated the facility assists residents in obtaining needed dental services including routing and emergency services to meet the needs of each resident. The P&P further indicated:

The facility will ensure the dentist provides dental services in accordance with professional standards of quality and timeliness.

The facility shall attempt to find alternative funding sources or alternative service delivery systems for residents unable to pay for needed dental services.

When necessary, or if requested by the resident or their interested party, the facility will assist the resident in making appointments and arrange for transportation to and from the dental services location.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 44244

Residents Affected - Few Based on observation, interview, and record review, the facility failed to honor resident dietary preferences for one of eight sampled residents (Resident 59) reviewed under the Food care area by failing to ensure the resident was not served fish, a disliked food, at lunch on 2/28/2025.

This deficient practice had the potential to result in the resident having a decreased meal intake which could lead to unintentional weight loss and malnutrition (lack of sufficient nutrients in the body).

Findings:

During a review of Resident 59 ' s Admission Record, the Admission Record indicated the facility admitted

the resident on 1/27/2025 with diagnoses that included myocardial infarction (MI - heart attack), pneumonia (an infection/inflammation in the lungs), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and malignant neoplasm of right female breast (breast cancer [a disease in which some of the body ' s cells grow uncontrollably and spread to other parts of the body]).

During a review of Resident 59 ' s Minimum Data Set (MDS - resident assessment tool), dated 2/3/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required supervision / touching assistance with eating.

During a review of Resident 59 ' s Dietary Profile (a written collection of information about a resident's diet), dated 1/29/2025, the Dietary Profile indicated the resident disliked fish and the resident ' s meal ticket was updated.

During a review of Resident 59 ' s Order Summary Report, the Order Summary Report indicated a dietary order for consistent carbohydrate, low sodium diet, regular texture, thin liquid consistency, gluten free, dated 1/29/2025.

During a review of Resident 59 ' s Care Plan (CP) regarding the resident ' s diet, initiated 1/28/2025, the CP indicated to provide food preferred if not in conflict with the treatment plan.

During an interview, on 2/24/2025, at 3:34 p.m., with Resident 59, Resident 59 stated that the facility serves food items that Resident 59 has an intolerance to or dislikes.

During an interview, on 2/26/2025, at 12:57 p.m., with the Dietary Supervisor (DS), the DS stated the kitchen staff is aware that Resident 59 has dietary intolerances and food dislikes, and the resident should not be served those items. The DS stated the kitchen staff ensures Resident 59 is not served food dislikes / intolerances by following the resident ' s meal ticket (a list of items that specifies the food and fluids a resident should receive) which indicates these dislikes/intolerances based on the resident ' s dietary profile.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During a concurrent observation and interview, on 2/28/2025, at 1:15 p.m., with Resident 59, Resident 59 sat at bedside eating from the lunch tray. Resident 59 stated Resident 59 dislikes fish but was served seasoned Level of Harm - Minimal harm or fish. Resident 59 ' s plate contained fish. potential for actual harm

During a concurrent observation, interview, and record review, on 2/28/2025, at 1:20 p.m., with Certified Residents Affected - Few Nursing Assistant (CNA) 6, Resident 59 ' s Lunch meal ticket, dated 2/28/2025, was reviewed and indicated Resident 59 does not like fish. CNA 6 stated the lunch tray is reviewed prior to being delivered to the resident and, if the meal ticket indicates the resident does not like fish, the resident should not be served fish. CNA 6 entered Resident 59 ' s room and reviewed the resident ' s meal ticket and lunch tray and stated the meal ticket indicates the resident dislikes fish, but the resident was served fish.

During an interview, on 2/28/2025, at 1:38 p.m., with the DS, the DS stated she was made aware that Resident 59 was served fish for lunch on 2/28/2025 and the resident should not have been served fish because the resident dislikes fish. The DS stated a lot of staff member ' s eyes missed that the resident had fish on her lunch plate. The DS stated when Resident 59 was served a disliked food, it can affect the resident because the resident may feel unhappy because the facility failed the resident.

During an interview, on 2/28/2025, at 2 p.m., with the Director of Nursing (DON), the DON stated when Resident 59 was served fish and the resident disliked fish, the resident may have felt disappointed. The DON stated feeling disappointed may cause psychosocial issues affecting the resident ' s well-being and may potentially lead to unwanted weight loss in the resident.

During a review of the facility policy and procedure (P&P) titled, Food and Nutritional Services, last reviewed 12/3/2024, the P&P indicated the facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. The facility provides each resident with

a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The facility has an ongoing communication and coordination among and between staff within all departments to ensure the resident assessment, care plan and food and nutrition services meet each resident's daily nutritional and dietary needs and choices. Residents are offered meaningful choices in meals/diets that are nutritionally adequate and satisfying to the individual. Reasonable efforts to accommodate these choices and preferences are addressed by facility staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

Two dented cans were found with the non-dented cans.

One opened bag of crushed graham crackers did not indicate the date of when it was opened.

These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 128 of 150 medically compromised residents.

Findings:

1. During a concurrent observation and interview on, 2/24/2025, at 8:30 a.m., with the Dietary Manager (DM), inside the dry storage room, the DM confirmed and stated there were two dented cans not placed in the dented can area. The DM stated it was missed during the daily inspection of dented cans by one of the kitchen staff. The DM stated it was important to separate the dented cans from non-dented cans to avoid using it for residents as the seal of the dented cans had already been broken and can release chemical which can cause cross-contamination.

2. During a concurrent observation and interview, on 2/24/2025, at 8:30 a.m., inside the dry storage room with the DM, the DM confirmed and stated an opened box of graham cookie crumbs did not indicate the date of when it was opened. The DM stated any opened items in the kitchen are labeled with the date they were opened for the staff to know until when can they use the opened items. The DM stated the kitchen staff should have labeled the graham cookie crumbs with the date it was opened so the staff would know that the graham cookie crumbs were not beyond the recommended shelf life of three (3) months for all items in the dry storage room

During a review of Food Code 2022, dated 1/18/2023, Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601. 12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a review of the facility provided product shelf-life guide titled A Shelf Life Guide,, undated, the product shelf-life guide indicated recommendations for pantry stored crackers after opening has a shelf life of one Level of Harm - Minimal harm or month. potential for actual harm

During a review of the facility ' s policy and procedure (P&P) titled, Food Storage, last reviewed on Residents Affected - Some 12/3/2024, the P&P indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice. The P&P further indicated:

VIII Canned Fruit Storage Guidelines

C. Dented or bulging cans should be placed in a separate storage area and returned for credit.

- XIII Dry Storage Guidelines

G. Any opened products should be placed in storage containers with tight fitting lids.

H. Label and date storage products.

During a review of Food Code 2022, dated 1/18/2023, Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture ' s use-by- date if the manufacturer determined the use-by date based on food safety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review the facility failed to maintain an infection prevention and Residents Affected - Few control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to:

1. Ensure Certified Nursing Assistant (CNA) 2 did not place the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) from the floor onto the resident's bed for one of three sampled residents (Resident 101) reviewed under the Respiratory care area.

2. Perform hand hygiene and putting on a gown prior to performing activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care residents on enhanced barrier precautions (EBP - extra steps to prevent the spread of germs by wearing special protective gear, like gowns and gloves, when caring for someone who might have a highly contagious infection) for one (1) of two (2) sampled residents (Resident 65) reviewed under the Infection Control task.

These deficient practices had the potential to spread infections and illnesses among residents and staff.

Findings:

a. During a review of Resident 101's Admission Record, the Admission Record indicated the facility admitted

the resident on 5/15/2024 with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dependence on supplemental oxygen, and encounter for palliative care (specialized medical care for people living with a serious illness).

During a review of Resident 101's Minimum Data Set (MDS - resident assessment tool), dated 2/4/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident had no impairment of upper or lower extremities and was dependent on staff for oral and personal hygiene, toileting, bathing, and dressing. The MDS indicated the resident required oxygen therapy while a resident in the facility.

During a review of Resident 101's Order Summary Report, dated 1/29/2025, the Order Summary Report indicated an order for oxygen at 2 to four liters per minute (LPM - a unit of measurement) via NC continuously. Monitor and document oxygen saturation (O2 Sat - a measurement of the percentage (%) of oxygen in the blood) every shift. May titrate to maintain oxygen saturation greater than 91%.

During a review of Resident 101's Care Plan (CP) titled, Refusal/Removing of oxygen therapy. Non-compliance with care. With episodes of removing oxygen tubing/devices, initiated 9/5/2024, the CP indicated to re-apply the oxygen tubing when resident is needing it.

During an observation, on 2/25/2025, at 11:10 a.m., Resident 101 laid in bed and the NC was on the ground.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview, on 2/25/2025, at 11:12 a.m., with CNA 2, CNA 2 entered Resident 101's room. CNA 2 picked up the NC, coiled the NC tubing, and placed the NC on Resident 101's Level of Harm - Minimal harm or bed next to the resident's right hand. CNA 2 stated Resident 101's NC was on the ground, and she placed potential for actual harm the NC from the ground onto the resident's bed. CNA 2 exited Resident 101's room and the NC remained on

the resident's bed within reach of the resident. Residents Affected - Few

During an interview, on 2/25/2025, at 11:15 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated CNA 2 notified LVN 2 that Resident 101's NC needed to be changed because it was on the ground. LVN 2 stated the NC was now on the bed. LVN 2 stated CNA 2 should not have placed the NC on the resident's bed after the NC had been on the ground. LVN 2 stated when the NC was placed on the bed it was an infection control issue. LVN 2 stated CNA 2 should have removed or left the NC on the ground until it was replaced, but she did not.

During an interview, on 2/27/2025, at 12:01 p.m., with the Infection Preventionist (IP), the IP stated NCs are changed weekly and kept in a storage bag when not in use to prevent bacteria from contaminating the NC.

The IP stated the NC should not be placed on a resident's bed if it was previously on the floor. The IP stated when a NC is on the floor and then placed on the bed there was a potential that bacteria from the dirty floor could transfer to the resident's bed or directly to the resident if they put on the NC.

During an interview, on 2/28/2025, at 11 a.m., with the Director of Nursing (DON), the DON stated CNA 2 should not have placed Resident 101's NC from the floor to the bed. The DON stated CNA 2 should have left

the NC on the floor and called the nurse to replace it. The DON stated the floor is dirty and could potentially cause cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) resulting in an infection in Resident 101. The DON stated the facility's policy and procedure (P&P) was not followed when CNA 2 placed Resident 101's NC on the bed after the NC was on the floor.

During a review of the facility's P&P titled, Infection Prevention and Control Program, last reviewed 12/3/2024, the P&P indicated the purpose of the policy was to ensure the facility establishes and maintains

an infection control program designed to provide a safe sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements. Infection prevention and control program standards apply to all facility employees who provide care and services to residents.

During a review of the facility P&P titled, Oxygen Therapy, last reviewed 12/3/2024, the P&P indicated the purpose was to provide guidelines for the administration of oxygen. The NC is a tube that is placed approximately one-half inch into the resident's nose. All NCs used to deliver oxygen will be changed weekly and when visibly soiled and will be stored in a plastic bag at the resident's bedside to protect equipment from dust and dirt when not in use.

43988

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 b. During a review of Resident 65's Admission Record, the Admission Record indicated the facility originally admitted the resident on 2/8/2021 and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes Level of Harm - Minimal harm or mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), potential for actual harm calculus of gallbladder (also known as gallstones, are hardened deposits of fats and bile [a fluid that is made and released by the liver and stored in the gallbladder] which aids with digestion) calcium salts that form in Residents Affected - Few the [gallbladder - a small, pear-shaped organ that stores and releases bile to help digest food]), and generalized muscle weakness.

During a review of Resident 65's History and Physical (H&P), dated 1/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions.

During a review of Resident 65's MDS, dated [DATE REDACTED], the MDS indicated Resident 65 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with toileting hygiene, bathing, and lower body dressing; substantial/maximal assistance from staff with all other ADLs.

During a review of Resident 65's Order Summary Report, dated 1/16/2025, the Order Summary Report indicated a physician's order for EBP due to medical device right upper abdomen (RUA) biliary drain (a thin, flexible tube inserted into the bile duct to help drain excess bile if the duct is blocked, allowing the bile to flow out into a collection bag outside the body).

During a review of Resident 65's CP on EBP related to medical device (RUA biliary drain), initiated on 1/16/2025 and last revised on 1/24/2025, the CP indicated health teaching to resident, family members, and staff about importance of EBP including proper hand hygiene and wearing of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during high-contact resident activities as one of the interventions to minimize risk and complications of infection.

During an observation, on 2/24/2025, at 10:21 a.m., inside Resident 65's room, CNA 1 put on gloves without performing hand hygiene and grabbed three (3) wash cloths inside a plastic bag on top of Resident 65's bed. CNA 1 went to the bathroom, wet the washcloths, and started wiping Resident 65's eyes from the inside corner to outer corner with one wash cloth, placed the 3 washcloths on top of the overbed table that was not cleaned or sanitized, and left the room without removing her gloves.

During a concurrent observation and interview, on 2/24/2025, at 10:27 a.m., inside Resident 65's room, with CNA 1, CNA 1 put on gloves without performing hand hygiene and started providing ADL care to Resident 65 using the washcloths placed on top of the overbed table. CNA 1 stated she did not know Resident 65 was

on EBP, and she did not pay attention to the EBP sign taped at the doorway. CNA 1 was unable to answer why Resident 65 was on EBP. CNA 1 stated staff are supposed to wear PPEs while providing care to residents who are on EBP to prevent spread of infection among residents. CNA 1 stated she should have paid attention to the EBP sign at the door, performed hand hygiene, and put on the proper PPE prior to providing ADL care to Resident 65 to prevent spread of infection to the other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview, on 2/24/2025, at 10:30 a.m., inside Resident 65's room, with LVN 9, LVN 9 stated staff are supposed to perform hand hygiene and put on the proper PPEs prior to Level of Harm - Minimal harm or performing high contact activities to residents on EBP to prevent spread of infection among residents and potential for actual harm staff. LVN 9 stated Resident 65 was on EBP due to presence of RUA biliary drain. LVN 9 told CNA 1 that she should have put on a gown while providing care to Resident 65. LVN 9 stated CNA 1 should have performed Residents Affected - Few proper hand hygiene and put on the proper PPEs prior to providing care to Resident 65.

During an interview, on 2/27/2025, at 12:05 p.m., with the IP, the IP stated residents on EBP are identified by blue colored sign at the door indicating a number 1 for the resident in bed 1 and number 2 for the resident in bed 2. The IP stated staff must perform the proper hand hygiene using a hand sanitizer or washing their hands and put on the proper PPEs prior to performing high contact activities to residents on EBP such as the presence of any tubes or catheters, wounds, changing linens, providing ADL care. The IP stated CNA 1 should have performed the proper hand hygiene and put on the proper PPEs prior to providing care to Resident 65 to prevent or stop the spread of infection or cross contamination between the residents and staff.

During an interview, on 2/28/2025, at 1:00 p.m., with the DON, the DON stated that all staff were supposed to perform the proper hand hygiene and put on the proper PPEs prior to performing high contact activities such as providing ADL care to any resident on EBP. The DON stated CNA 1 should have performed proper hand hygiene using the hand sanitizer or washing her hands and put on the proper PPEs prior to providing ADL care to Resident 65 as she was on EBP due to presence of RUA biliary drain to prevent cross contamination and spread of infection among residents and staff.

During a review of the facility's P&P titled, Enhanced Barrier Precautions, last reviewed on 12/3/2024, the P&P indicated the facility will utilize guidance to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection. The P&P further indicated:

- I. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.

- II. EBP are indicated for residents with any of the following:

B. Wounds and/or indwelling medical devices even if the resident is not known to be

infected or colonized with a multidrug resistant organism (MDRO).

- IV. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

During a review of the facility's P&P titled, Infection Prevention and Control Program, last reviewed on 12/3/2024, the P&P indicated the facility establishes and maintains an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 92 555904

F-F756

Findings:

During a review of Resident 101's Admission Record (a document containing a resident's diagnostic and demographic information), dated 2/27/2025, the Admission Record indicated she was admitted to the facility

on [DATE REDACTED] with diagnoses including: anxiety disorder (a mental illness characterized by persistent worry or fear strong enough to interfere with daily life).

During a review of Resident 101's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 1/3/2025, the H&P indicated she had worsening functional and cognitive decline but did not indicate whether she had the capacity to understand and make decisions.

During a review of Resident 101's Physician Order Summary (a monthly summary of all active physician orders), dated 2/26/2025, the Physician Order Summary indicated she was prescribed guaifenesin oral liquid to take 10 milliliters (ml - a unit of measure for volume) by mouth every four hours as needed for congestion

on 11/30/2024. Further review of the order for guaifenesin indicated there was no stop date indicated.

During a review of the consultant pharmacist's recommendation, dated 12/31/2024, the consultant pharmacist's recommendation indicated the consultant pharmacist advised the facility to indicate the length of therapy for PRN guaifenesin oral liquid as the facility's policy for the duration of cough and cold products is limited to 10 days. Further review of the pharmacist's recommendation indicated no apparent facility response.

During an interview on 2/26/2025 at 3:27 p.m., with the Director of Nursing (DON), the DON stated the facility failed to define or limit the use of guaifenesin oral liquid to 10 days per the facility policy. The DON stated the failure to limit PRN medications per the requirements and recommendations of the pharmacist increased the risk that Resident 101 may have received them when it had become clinically inappropriate. The DON stated

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. The DON stated the failure to limit Resident 101's PRN medications per the requirements also increased the risk that she may have experienced adverse effects related to the medications which could have contributed to a decline in her quality of life.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 During a review of the facility's policy Stop Orders, revised April 2018, the policy indicated The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically Level of Harm - Minimal harm or after the indicated number or days, unless the prescriber specifies a different number of doses or duration of potential for actual harm therapy to be given . cough and cold preparations 10 days.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 Residents Affected - Some Based on interview and record review, the facility failed to:

1. Perform a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication or discontinue a medication in order to control a resident's symptoms with lower doses or fewer medications) for psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in two of five residents sampled for unnecessary medications (Residents 1 and 71.)

2. Limit the duration of PRN (as needed) lorazepam (a medication used to treat mental illness) to 14 days or document a longer, specific duration and clinical rationale in one of five residents sampled for unnecessary medications (Resident 101.)

3. Ensure the antipsychotic medication (a class of medications used to treat mental illness), quetiapine (an antipsychotic medication used to treat mental illness) was used for a clear indication or diagnosed condition as documented in the clinical record for one of five residents sampled for unnecessary medications (Resident 68.)

4. Monitor for the target behaviors of physical aggression related to the use of quetiapine in one of five residents sampled for unnecessary medications (Resident 68.)

5. Document behaviors of repetitive physical movements and restlessness related to the use of PRN alprazolam (a medication used to treat mental illness) in the February 2025 Medication Administration

Record (MAR - a record of all medications administered and monitoring documented for a resident) for one of five residents sampled for unnecessary medications (Resident 347.)

6. Ensure sertraline (a medication used to treat depression [a mental illness defined by depressed mood, trouble sleeping, and lack of interest in activities]) and escitalopram (a medication used to treat depression) were not used simultaneously without clinical justification in one of five residents sampled for unnecessary medications (Resident 347.)

The deficient practices of failing to perform GDRs, limit the duration of PRN orders for psychotropic medications, use antipsychotics for a clear indication, monitor and document target behaviors, and avoid therapeutic duplication of antidepressant therapy increased the risk that Residents 1, 68, 71, 101, and 347 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 1.a. During a review of Resident 1's Admission Record (a document containing a resident's diagnostic and demographic information), dated 2/27/2025, the Admission Record indicated she was admitted to the facility Level of Harm - Minimal harm or on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including: Major Depressive Disorder potential for actual harm (MDD - a mental illness defined by depressed mood, trouble sleeping, and lack of interest in activities) and anxiety disorder (a mental illness characterized by persistent worry or fear strong enough to interfere with Residents Affected - Some daily life.)

During a review of Resident 1's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 1/22/2025, the H&P indicated she had the capacity to understand and make decisions.

During a review of Resident 1's Physician Order Summary (a monthly summary of all active physician orders), dated 2/26/2025, the Physician Order Summary indicated she was prescribed the following:

1. Lorazepam 0.5 milligrams (mg - a unit of measure for mass) by mouth one time a day for anxiety manifested by inconsolable drying and excessive worrying on 7/27/2024.

2. Sertraline 50 mg by mouth one time a day for depression manifested by verbalization of sadness on 7/27/2024.

During a review of the consultant pharmacist's (a medical professional responsible for a monthly review of all residents' medication regimens) recommendations, dated 1/31/2025, the consultant pharmacist's recommendations indicated the pharmacist recommend a GDR for Resident 1's sertraline and lorazepam. Further review of the pharmacist's recommendation indicated the psychiatric nurse practitioner (NP) agreed and indicated to decrease the dosage of sertraline from 50 mg daily to 25 mg daily and to discontinue the lorazepam.

During a review of Resident 1's Psychiatric Progress Note (clinical documentation of a psychiatric treatment professional's assessment and treatment plan), authored by NP and dated 2/24/2025, the Psychiatric Progress Note indicated the plan was to Decrease sertraline 25 mg oral tablet QD (every day). Discontinue lorazepam tablet 0.5 mg QD. Please refer to updated physician's orders & MAR.

1.b. During a review of Resident 71's Admission Record, dated 2/27/2025, the Admission Record indicated

she was admitted to the facility on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including: MDD.

During a review of Resident 71's History and Physical (H&P), dated 11/23/2024, the H&P indicated she had

the capacity to understand and make decisions.

During a review of Resident 71's Physician Order Summary, dated 2/26/2025, the Physician Order Summary indicated she was prescribed amitriptyline 50 mg at bedtime for depression manifested by loss of interested

in most normal activities on 10/23/2024.

During a review of the consultant pharmacist's recommendations, dated 1/31/2025, the consultant pharmacist's recommendations indicated the pharmacist recommend a GDR for Resident 71's amitriptyline. Further review of the pharmacist's recommendation indicated NP agreed and indicated to decrease the dosage of amitriptyline from 50 mg to 25 mg at bedtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a review of Resident 71's Psychiatric Progress Note, authored by NP and dated 2/24/2025, the Psychiatric Progress Note indicated the plan was to Decrease amitriptyline tablets 25 mg QHS (at bedtime). Level of Harm - Minimal harm or Please refer to updated physician's orders & MAR. potential for actual harm

During an interview on 2/26/2025 at 3:27 p.m. with the Director of Nursing (DON), the DON stated the Residents Affected - Some pharmacist's recommendations on 1/31/2025 indicated NP responded to a GDR request for Resident 1's sertraline to decrease the dose from 50 mg daily to 25 mg and to discontinue the lorazepam and to decrease Resident 71's dose of amitriptyline from 50 mg to 25 mg at bedtime. The DON stated, according to the NP's psychiatric notes, dated 2/24/2025, NP's plan was to decrease Resident 1's sertraline from 50mg to 25 mg and discontinue the lorazepam and to reduce Resident 71's dose of amitriptyline from 50 mg to 25 mg at bedtime. The DON, stated, despite these records, 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 and Resident 71 was still receiving 50 mg of amitriptyline because NP had not yet issued the new orders. The DON stated no one from the facility followed up with NP after reviewing the response to the pharmacist's recommendations or the psychiatric notes indicating the GDRs to obtain any needed orders. The DON stated, as a result, the facility failed to implement the gradual dosage reduction of Resident 1's sertraline from 50mg to 25mg or discontinue the lorazepam or to decrease Resident 71's dosage of amitriptyline from 50 mg to 25 mg at bedtime. The DON stated using sertraline, lorazepam, or amitriptyline at a higher dose than necessary increased the risk that Residents 1 and 71 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.

2. During a review of Resident 101's Admission Record, dated 2/27/2025, the Admission Record indicated

she was admitted to the facility on [DATE REDACTED] with diagnoses including: anxiety disorder (a mental illness characterized by persistent worry or fear strong enough to interfere with daily life.)

During a review of Resident 101's H&P, dated 1/3/2025, the H&P indicated she had worsening functional and cognitive decline but did not indicate whether she had the capacity to understand and make decisions.

During a review of Resident 101's Order Audit Report (a report containing details and a timeline regarding a specific physician order), dated 2/26/2025, the Order Audit Report indicated she was prescribed lorazepam 2 mg per milliliter (ml - a unit of measure for volume) oral concentrate to take 1 ml by mouth every four hours as needed for anxiety between 5/15/2024 and 2/24/2025.

During a review of the consultant pharmacist's recommendation, dated 11/30/2024, the consultant pharmacist's recommendation indicated the consultant pharmacist advised the facility that PRN orders for lorazepam must be limited to 14 days or a specific duration with a corresponding clinical rationale must be documented. Further review of the pharmacist's recommendation indicated that the facility documented no new orders on 12/17/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During an interview on 2/26/2025 at 3:27 p.m., with the DON, the DON stated the facility failed to timely respond to the pharmacist's recommendation to limit PRN lorazepam to 14 days. The DON stated the facility Level of Harm - Minimal harm or failed to limit the duration of Resident 101's PRN lorazepam to 14 days or document a longer duration and potential for actual harm rationale between 5/15/2024 and 2/24/2025. The DON stated the failure to limit PRN medications per the requirements and recommendations of the pharmacist increased the risk that Resident 101 may have Residents Affected - Some received them when it had become clinically inappropriate. The DON stated 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. The DON stated the failure to limit Resident 101's PRN medications per the requirements also increased the risk that she may have experienced adverse effects related to the medication which could have contributed to a decline in her quality of life.

3. During a review of Resident 68's Admission Record, dated 2/27/2025, the Admission Record indicated she was admitted to the facility on [DATE REDACTED] with diagnoses including: dementia (a group of progressive medical conditions affecting the brain that interfere with the ability to remember, think clearly, and make decisions.)

During a review of Resident 68's H&P, dated 1/24/2025, the H&P indicated she did not have the capacity to understand and make decisions.

During a review of Resident 68's Order Audit Report, dated 2/26/2025, the Order Audit Report indicated she was prescribed quetiapine 75 mg by mouth at bedtime for adjunct treatment of depression manifested by physical aggression between 1/22/2025 and 1/29/2025.

During a review of Resident 68's MAR, for January 2025, the MAR indicated she received quetiapine 75 mg from 1/23/2025 to 1/28/2025. Further review of the MAR indicated the behavioral monitoring order related to Resident 68's quetiapine instructed licensed staff to monitor for verbal aggression rather than physical aggression.

During a review of Resident 68's Psychiatric Progress Note, authored by NP and dated 1/23/2025, the Psychiatric Progress Note indicated there was no discussion of Resident 68's need for adjunct treatment of depression (combining an antidepressant and an antipsychotic to better treat depression) with an antipsychotic medication including Resident 68's history of antidepressants tried and failed or any rationale for the combination therapy without having optimized the dose of her antidepressant first.

During a review of Resident 68's clinical record, the clinical record indicated no other documented rationale for the use of quetiapine or any medical or psychiatric history documenting the need for adjunct treatment for MDD.

During a review of Resident 68's Psychiatric Progress Note, authored by NP and dated 1/29/2025, the Psychiatric Progress Note indicated to discontinue Resident 68's quetiapine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a telephone interview, on 2/27/2025, at 8:56 a.m., with NP, NP stated he was not aware of Resident 68 needing quetiapine as adjunct therapy for MDD. NP stated this medication should not have been Level of Harm - Minimal harm or continued upon her admission to the facility as it was being given for agitation or anxiety during her hospital potential for actual harm stay prior to her admission to the facility. NP stated quetiapine was discontinued because the resident has dementia and to continue using this medication regularly put this resident at risk for sedation, dizziness, Residents Affected - Some drowsiness, increased risk of fall with injury, and unexplained death or stroke which outweighed any benefit

she may have received from it.

During an interview on 2/27/2025 at 9:20 a.m. with the DON, The DON stated when an antipsychotic medication is prescribed, it must have a clear indication and diagnosis documented in the resident's clinical record. The DON stated the facility failed to ensure Resident 68 had a clear indication for the use of quetiapine upon her admission to the facility. The DON stated Resident 68's behaviors related to MDD included loss of interest or pleasure in normal activities. The DON stated the target behaviors for using the quetiapine were physical aggression. The DON stated, if quetiapine was used as adjunct therapy to help sertraline better treat the symptoms of MDD, it doesn't make sense that it would have different target behaviors. The DON stated, because the use of quetiapine was not clearly defined in Resident 68's clinical record, the risks of continued quetiapine use, including dizziness, drowsiness, fall with injury and death, were increased and outweighed any benefits. The DON stated the facility failed to properly monitor for target behaviors related to the use of quetiapine. The DON stated the target behavior defined for the use of quetiapine for Resident 68 was physical aggression, however, according to the January 2025 MAR, the facility was monitoring for behaviors of verbal aggression. The DON stated, the monitoring order did not include the correct behaviors for which quetiapine was prescribed. The DON stated this may cause licensed nurses to not document episodes of physical aggression despite the resident exhibiting them. The DON stated it is important to properly monitor target behaviors related to antipsychotic use in order to periodically reassess whether the medication is effective at controlling those behaviors. The DON stated, if behaviors are not properly monitored, there is a risk that the resident may receive antipsychotic therapy for longer or at higher doses than necessary possibly leading to increased adverse effects of quetiapine and a decline in quality of life.

4. During a review of Resident 347's Admission Record, dated 2/27/2025, the Admission Record indicated

she was admitted to the facility on [DATE REDACTED] with diagnoses including: depression and anxiety.

During a review of Resident 347's clinical record, the clinical record indicated she did not yet have a History and Physical on file with the facility.

During a review of Resident 347 Order Summary Report, dated 2/27/2025, the Order Summary Report indicated she was prescribed the following:

1. Alprazolam 0.5 mg by mouth every six hours as needed for anxiety manifested by repetitive physical movements as evidenced by restlessness on 2/2021/2025.

2. Escitalopram 10 mg by mouth one time a day for depression manifested by loss of interest in most normal activities on 2/24/2025.

3. Sertraline 50 mg by mouth one time a day for depression manifested by loss of interest or pleasure in most or all normal activities on 2/2021/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a review of Resident 347's MAR, for February 2025, the MAR indicated she received PRN alprazolam

on 2/22, 2/23, and 2/24/2025, however, the behavioral monitoring order Related to Resident 347's Level of Harm - Minimal harm or alprazolam indicated there were no documented incidents of Resident 347 having repetitive physical potential for actual harm movements as evidenced by restlessness on those days or at any other time during February 2025.

Residents Affected - Some During a review of Resident 347's Psychiatric Progress Note, authored by NP and dated 2/24/2025, the Psychiatric Progress Note indicated Resident 347 was to receive both escitalopram and sertraline, but provided no discussion or rationale as to why Resident 347 would need two antidepressants of the same class simultaneously.

During a review of Resident 347's clinical record, the clinical record indicated there was no other documented clinical rationale for the use of both escitalopram and sertraline simultaneously.

During a telephone interview on 2/27/2025 at 8:56 a.m. with NP, NP stated it is not appropriate for Resident 347 to be on both escitalopram and sertraline at the same time. NP stated these medications are in the same class of antidepressant and are not commonly used at the same time. NP stated, on 2/24/2025, after seeing Resident 347, the resident stated she wanted to try a different antidepressant than sertraline. NP stated he gave the facility staff a verbal discontinue order for sertraline and prescribed escitalopram. NP stated it is possible this order was not communicated to the facility staff effectively. NP stated he was unaware that Resident 347 was receiving them simultaneously. NP stated using them together could cause additional adverse effects related to their use which could decrease Resident 347's quality of life.

During an interview on 2/27/2025 at 9:20 a.m. with the DON, the DON stated Resident 347's order for alprazolam is for PRN use so it should only be used when the resident is experiencing the symptoms or behaviors for which it is prescribed. The DON stated the February MAR between 2/2021 and 2/2025 indicate

this resident did not have any behaviors of Anxiety manifested by repetitive physical movements as evidenced by restlessness documented. The DON stated the February MAR also indicated that Resident 347 received alprazolam on 2/22, 2/23, and 2/24. The DON stated, although the licensed nurses are documenting the administration of PRN doses of alprazolam in the nurses' progress notes, they failed to document the behaviors on the behavioral monitoring order in the MAR. The DON stated it is important to document the behaviors in the MAR because the prevalence of behaviors documented there is used to determine if a medication is effective at controlling those behaviors. The DON stated, without documenting behaviors in the MAR, the medication cannot accurately be reevaluated to determine whether it is controlling Resident 347's symptoms of anxiety. The DON stated this could possibly result in the resident receiving a decrease in dosage or a discontinuation of the medication, resulting in a worsening of her anxiety and a decline in her quality of life.

During a review of the facility's policy titled, Psychotropic Medication - Gradual Reduction and PRN, revised March 2023, the policy indicated Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical

record . The facility implements gradual dose reductions (GDR) . unless contraindicated, prior to initiating or instead of continuing psychotropic medication . PRN orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days . the attending physician or prescribing practitioner shall document their rationale in the resident's medical record and indicate the duration for the PRN psychotropic order when the order extends beyond 14 days .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a review of the facility's policy titled, Antipsychotic Medications Use in Dementia, revised March 2023,

the policy indicated Antipsychotic medication therapy for residents with dementia shall be used only when it Level of Harm - Minimal harm or is necessary to treat a specific medical condition . Residents with dementia will only receive antipsychotic potential for actual harm medication when necessary to treat specific conditions for which they are indicated and effective . nursing staff will document in detail and individual's target symptoms . the staff will observe, document, and report to Residents Affected - Some the Attending Physician information regarding the effectiveness or any interventions, including antipsychotic medications .

During a review of the facility's policy titled, Stop Orders, revised April 2018, the policy indicated The following classes of medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number or days, unless the prescriber specifies a different number of doses or duration of therapy to be given . PRN anxiolytics . 14 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber ' s order, manufacturer ' s specifications, and accepted professional standards) for three of three sampled residents (Residents 65, 29 and 52) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites for (Residents 65, 29 and 52).

The deficient practice had the potential to result in an adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Additionally, the facility failed to ensure to administer three doses of levothyroxine as ordered for one of one sampled resident (Resident 197) reviewed for levothyroxine use.

This deficient practice had the potential to result in adverse effects (unwanted, unintended result) and serious health complications such as heart problems and impaired cognitive function.

Cross reference

F-F758

Findings:

During a review of Resident 101's Admission Record (a document containing a resident's diagnostic and demographic information), dated 2/27/2025, the Admission Record indicated she was admitted to the facility

on [DATE REDACTED] with diagnoses including: anxiety disorder (a mental illness characterized by persistent worry or fear strong enough to interfere with daily life).

During a review of Resident 101's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 1/3/2025, the H&P indicated she had worsening functional and cognitive decline but did not indicate whether she had the capacity to understand and make decisions.

During a review of Resident 101's Order Audit Report (a report containing details and a timeline regarding a specific physician order), dated 2/26/2025, the Order Audit Report indicated she was prescribed lorazepam 2 milligrams (mg a unit of measure for mass) per milliliter (ml - a unit of measure for volume) oral concentrate to take 1 ml by mouth every four hours as needed for anxiety between 5/15/2024 and 2/24/2025.

During a review of Resident 101's Physician Order Summary (a monthly summary of all active physician orders), dated 2/26/2025, the Physician Order Summary indicated she was prescribed guaifenesin oral liquid to take 10 ml by mouth every four hours as needed for congestion on 11/30/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During a review of the consultant pharmacist's recommendation, dated 11/30/2024, the consultant pharmacist's recommendation indicated the consultant pharmacist advised the facility that PRN orders for Level of Harm - Minimal harm or lorazepam must be limited to 14 days or a specific duration with a corresponding clinical rationale must be potential for actual harm documented. Further review of the pharmacist's recommendation indicated that the facility documented no new orders on 12/17/2024. Residents Affected - Some

During a review of the consultant pharmacist's recommendation, dated 12/31/2024, the consultant pharmacist's recommendation indicated the consultant pharmacist advised the facility to indicate the length of therapy for PRN guaifenesin oral liquid as the facility's policy for the duration of cough and cold products is limited to 10 days. Further review of the pharmacist's recommendation indicated no apparent facility response.

During an interview on 2/26/2025 at 3:27 p.m., with the Director of Nursing (DON), the DON stated the facility failed to timely respond to the pharmacist's recommendation to limit PRN lorazepam to 14 days and define

the length of therapy of guaifenesin oral liquid. The DON stated the facility failed to limit the duration of Resident 101's PRN lorazepam to 14 days or document a longer duration and rationale between 5/15/2024 and 2/24/2025. The DON stated the facility also failed to define or limit the use of guaifenesin oral liquid to 10 days per the facility policy. The DON stated the failure to limit PRN medications per the requirements and recommendations of the pharmacist increased the risk that Resident 101 may have received them when it had become clinically inappropriate. The DON stated 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. The DON stated the failure to limit Resident 101's PRN medications per the requirements also increased the risk that she may have experienced adverse effects related to the medications which could have contributed to a decline in her quality of life.

During a review of the facility's policy, Medication Regimen Review, undated, the policy indicated .The facility staff will encourage the physician/prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations including acceptance or rejection; and provide an explanation as to why the recommendations was rejected . The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to reevaluate or discontinue a PRN (as needed) Residents Affected - Few order for guaifenesin oral liquid (a medication used to treat cough/congestion) after 10 days in one of five residents sampled for unnecessary medications (Resident 101).

The deficient practice of failing to stop or reevaluate PRN medications increased the risk that Resident 101 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of guaifenesin possible resulting in a decline in her quality of life.

Cross-referenced to

F-F760

Findings:

a. During a review of Resident 65's Admission Record, the Admission Record indicated the facility originally admitted the resident on 2/8/2021 and readmitted Resident 65 on 1/10/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and generalized muscle weakness.

During a review of Resident 65's History and Physical (H&P) dated 1/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions.

During a review of Resident 65's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/17/2025, the MDS indicated Resident 65 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial to moderate a12ssistance with toileting hygiene, bathing, and lower body dressing; substantial to maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 65 received insulin.

During a review of Resident 65's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 1/28/2025:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 - Insulin lispro injection solution (a short acting insulin)100 unit per milliliter (unit/ml) inject subcutaneously

before meals and at bedtime for DM 2. Fingerstick blood sugar (FSBS - most common type of blood sugar Level of Harm - Minimal harm or monitoring) using lancets (a small needle) and test strips. Rotate injection site. Inject as per sliding scale potential for actual harm (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 units; if BS less than (<) 70 and awake give juice; if unresponsive, give Glucagon (a hormone that Residents Affected - Some raises blood sugar) 1 milligram (mg - a unit of measurement) intramuscularly (IM - inject into the muscle) and notify physician (MD); 150 - 199 = 4 units; 200 - 249 = 8 units; 250 - 299 = 12 units; 300 - 349 = 16 units; 350 plus = 20 units and notify MD.

During a review of Resident 65's care plan (CP) titled Risk for hypoglycemia (low blood sugar)/hyperglycemia (high blood sugar) related to diagnosis of DM 2 initiated on 1/13/2025 and last revised on 1/24/2025, the CP indicated to administer insulin lispro injection as ordered per sliding scale as one of the interventions to minimize complications related to DM 2.

During a concurrent interview and record review on 2/27/2025 at 12:22 p.m., Resident 65's physician's orders, Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) and Location of Administration Report for 2/2025 were reviewed with Licensed Vocational Nurse 3 (LVN 3). LVN 3 stated Resident 65 had a physician's order for insulin lispro which was administered as follows:

- Insulin lispro injection solution 100 unit/ml:

2/02/25 10:19 p.m. subcutaneously abdomen - left lower quadrant (LLQ)

2/03/25 4:29 p.m. subcutaneously abdomen - LLQ

2/03/25 11:31 subcutaneously abdomen - LLQ

2/06/25 4:54 p.m. subcutaneously abdomen - right lower quadrant (RLQ)

2/06/25 8:02 p.m. subcutaneously abdomen - RLQ

2/08/25 12:25 p.m. subcutaneously abdomen - LLQ

2/08/25 4:08 p.m. subcutaneously abdomen - LLQ

2/12/25 8:26 p.m. subcutaneously abdomen - RLQ

2/13/25 5:59 a.m. subcutaneously abdomen - RLQ

2/15/25 11:43 a.m. subcutaneously abdomen - LLQ

2/15/25 5:26 p.m. subcutaneously abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 LVN 3 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 3 stated Resident 65's MAR indicated the insulin Level of Harm - Minimal harm or administration sites were not rotated although, there was a physician's order to rotate injection sites. LVN 3 potential for actual harm stated Resident 65's insulin administration sites should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident's skin. Residents Affected - Some

During an interview on 2/28/025 at 1 p.m. Resident 65's physician's orders, MAR Location of Administration Report for 2/2025 was reviewed with the Director of Nursing (DON). The DON stated the location of administration sites for Resident 65's insulin were not rotated. The DON stated the charge nurses (CN) are supposed to rotate insulin administration sites according to standards of practice, as indicated in the manufacturer's guideline, and physician's order. The DON stated Resident 65 had a physician's order to rotate injection sites. The DON stated Resident 65's administration sites for insulin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin.

During a review of the facility provided undated, manufacturer's guideline for insulin lispro, the manufacturer's guideline indicated:

- Change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

- Do not inject where the skin has pits, is thickened, or has lumps.

- Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin.

- Choose your injection site: insulin lispro is injected under the skin of your stomach area, buttocks, upper legs or upper arms.

During a review of the facility's recent policy and procedure titled Insulin Administration, last reviewed on 12/3/2024, the P&P indicated the injection sites should be rotated to reduce the risk of damaging the skin tissue.

44376

b. During a review of Resident 29's Admission Record, the Admission Record indicated the facility admitted

the resident on 1/22/2025, with diagnoses including type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar [glucose] levels to be abnormally high), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls).

During a review of Resident 29's History and Physical (H&P), dated 1/23/2025, the H&P indicated the resident was on deep vein thrombosis (DVT, a blood clot in a vein deep in the body, usually in the leg) prophylaxis (an attempt to prevent disease) of heparin subcutaneous (sq, beneath, or under, all the layers of

the skin) and had the ability to make self-understood and understand others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 1/29/2025,

the MDS indicated the resident had the ability to make self-understood and understand others and had intact Level of Harm - Minimal harm or cognition (person's cognitive abilities like memory, understanding, problem-solving etc. are working usually in potential for actual harm all fundamental ways). The MDS indicated the resident was on an anticoagulant and hypoglycemic (a class of drugs that help lower blood sugar levels) medications. Residents Affected - Some

During a review of Resident 29's Order Summary Report, the Order Summary Report indicated an order for:

1/22/2025 Heparin Sodium (Porcine) Injection Solution 5000 unit per milliliters (unit [s an amount approximately equivalent to 0.002 mg of pure heparin]/ml [ a unit of volume]) (Heparin Sodium (Porcine). Inject one milliliter subcutaneously three times a day for DVT prophylaxis and rotate injection sites.

1/22/2025 Heparin: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (small red or purple spots on the skin or inside the mouth that are caused by broken blood vessels), internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by (+)YES or(-)NO. Notify MD if (+). Every shift.

1/27/2024 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal.): if 70 - 149 = 0, If blood sugar (BS) is less than 70 & awake, given orally (PO) juice. If unresponsive give Glucagon (a hormone that raises blood sugar [glucose]) 1 milligram (mg, a unit of weight) intramuscular (IM, within or into the muscle), notify MD.; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350+ = 6 units. Notify MD, subcutaneously before meals and at bedtime for Type 2 diabetes mellitus rotate injection site.

During a review of Resident 29's Location of Administration Report of Humulin R and Heparin Sodium for 1/2025 to 2/2025, the Location of Administration Report indicated Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered subcutaneously on:

1/24/2025 at 9:03 p.m. on the Abdomen - Left Lower Quadrant (LLQ)

1/25/2025 at 6:37 a.m. on the Abdomen - LLQ

And Humulin R Injection Solution 100 unit/ml was administered subcutaneously on:

1/29/2025 at 5:33 a.m. on the Abdomen - LLQ

1/29/2025 at 12:23 p.m. on the Abdomen - LLQ

2/14/2025 at 8:22 p.m. on the Abdomen - Left Upper Quadrant (LUQ)

2/15/2025 at 8:46 p.m. on the Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a concurrent interview and record review on 2/26/2025, at 8:47 a.m., with Registered Nurse (RN) 1, Resident 29's Location of Administration Report for Humulin R and Heparin Sodium for 1/2025 to 2/2025. RN Level of Harm - Minimal harm or 1 stated there were multiple instances where the licensed staff did not rotate the subcutaneous potential for actual harm administration of heparin and Humulin R on the resident. RN 1 stated it was important to rotate heparin and Humulin R administration sites to prevent excessive bruising and lipodystrophy on residents. Residents Affected - Some

During an interview on 2/28/2025, at 9:04 a.m., with the Director of Nursing (DON), the DON stated the licensed staff should have rotated Humulin R and heparin subcutaneous administration sites of Resident 29 to prevent adipose tissue (a connective tissue that extends throughout your body) buildup on the frequented site, discoloration, and hardening of the skin which can affect absorption of the medication. The DON added there was no reason for the licensed staff to repeat administration sites as it appears on the electronic healthcare record where the last subcutaneous administration of heparin and Humulin R was given.

During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 12/3/2024, the P&P indicated the injection sites should be rotated to reduce the risk of damaging the skin tissue.

During a review of the facility-provided Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982, the Highlights of Prescribing Information indicated subcutaneous injection: inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Highlights of prescribing Information on the use of Heparin Sodium Injection, USP for intravenous or subcutaneous use, with initial U.S. approval in 2009, the Highlights of Prescribing Information indicated under method of administration for deep subcutaneous (intrafat) injection, a different site should be used for each injection to prevent the development of massive hematoma.

c. During a review of Resident 52's Admission Record, the Admission Record indicated the facility admitted

the resident on 6/6/2024, with diagnoses including type 2 diabetes mellitus, gastro-esophageal reflux disease (GERD, a condition where stomach acid flows into the esophagus), and dysphagia (swallowing difficulties).

During a review of Resident 52's H&P, dated 6/21/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 52's MDS, dated [DATE REDACTED], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognitive skills (a condition that makes it difficult for someone to think, learn, remember, and make decisions) for daily decision making.

The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a review of Resident 52's Order Summary Report, dated 2/22/2025, the Order Summary Report indicated an order for Insulin NPH (Human) (Isophane) Subcutaneous Suspension Pen-injector 100 unit/ml Level of Harm - Minimal harm or (Insulin NPH [Human] [Isophane]), the report indicated to inject 18 units subcutaneously two times a day for potential for actual harm diabetes/hyperglycemia (a condition in which there is too much glucose in the blood, also known as high blood sugar). Rotate injection sites and hold for blood sugar (BS) less than (<) 100. Residents Affected - Some

During a review of Resident 52's Location of Administration Report of Insulin NPH (Isophane) for 1/2025 to 2/2025, the Location of Administration Report indicated Insulin NPH (Isophane) Subcutaneous Suspension Pen-Injector 100 unit/ml was administered on:

1/5/2025 at 5:10 a.m. on the Abdomen - LLQ

1/5/2025 at 6:04 p.m. on the Abdomen - LLQ

1/19/2025 at 5:11 a.m. on the Abdomen - LLQ

1/19/2025 at 5:05 p.m. on the Abdomen - LLQ

2/7/2025 at 5:08 p.m. on the Abdomen - Right Lower Quadrant (RLQ)

2/8/2025 at 6:55 a.m. on the Abdomen - RLQ

During a concurrent interview and record review on 2/26/2025, at 8:55 a.m., with RN 1, reviewed Resident 52's Location of Administration Report for Insulin NPH (Isophane) for 1/2025 to 2/2025. RN 1 stated there were multiple instances where the licensed staff did not rotate the subcutaneous administration of Insulin NPH (Isophane) on the resident. RN 1 stated it was important to rotate Insulin NPH (Isophane) administration sites to prevent excessive bruising and lipodystrophy on residents.

During an interview on 2/28/2025, at 9:04 a.m., with the DON, the DON stated the licensed staff should have rotated Insulin NPH (Isophane) subcutaneous administration sites of Resident 52 to prevent adipose tissue buildup on the frequented site, discoloration and hardening of the skin which can affect absorption of the medication. The DON added there was no reason for the licensed staff to repeat administration sites as it appears on the electronic healthcare record where the last subcutaneous administration of Insulin NPH (Isophane) was given.

During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 12/3/2024, the P&P indicated the injection sites should be rotated to reduce the risk of damaging the skin tissue.

During a review of the facility-provided Consumer Information on the use of Humulin N vials insulin isophane, human biosynthetic (rDNA origin), suspension for injection, 100 [NAME]/mL, the Consumer Information indicated to avoid tissue damage (skin thinning, skin thickening, or skin lumps), always change the site for each injection by at least 1.5 cm (0.5 inches) from the previous site, rotating sites of the body so that the same site is not used more than approximately once a month. Do not inject into pits (depressions), thickened skin or lumps.

38552

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 d. During a review of Resident 197's Admission Record, the Admission record indicated the resident was admitted on [DATE REDACTED] with diagnoses that included the presence of a left artificial hip joint, hypertensive heart Level of Harm - Minimal harm or disease (high blood pressure), and hypothyroidism (underactive thyroid, happens when your thyroid gland potential for actual harm doesn't make enough thyroid hormones to meet your body's needs).

Residents Affected - Some During a review of Resident 197's physician order, dated 2/17/2025, indicated levothyroxine sodium oral tablet 75 micrograms (mcg-a unit of measurement) give one tablet by mouth one time a day for hypothyroidism.

During a review of Resident 197's History and Physical, dated 2/18/2025, the H & P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 197's Care Plan Report, dated 2/18/2025, the care plan report indicated Resident 197 has hypothyroidism and required daily thyroid replacement. The Care Plan Report included interventions to administer thyroid replacement therapy as ordered and to monitor or document side effects and effectiveness done by the licensed nurses.

During an interview on 2/24/2025 at 10:18 a.m. with Resident 197, Resident 197 stated she has been here since 2/17/2025 and she has only received her thyroid medication only two to three times this week. Resident 197 stated she has not received her thyroid medication this morning.

During a concurrent observation and interview on 2/27/2025 at 6:23 a.m. with Licensed Vocational Nurse (LVN) 1, while in Nursing Station 1, Resident 197's levothyroxine bubble pack was inside the medication cart. LVN 1 stated the levothyroxine 75 mcg tablet bubble pack was filled on 2/17/2025 with a total of five (5) doses/tablets were administered. LVN 1 stated he has not administered today's dose yet because the resident prefers to receive it at 7 a.m.

During a concurrent interview and record review on 2/28/2025 at 7:17 a.m. with LVN 1, Resident 197's Medication Administration Record (MAR), dated 2/1/2025 - 2/28/2025 was reviewed. The MAR indicated, a total of 10 doses of levothyroxine were administered from 2/18/2025 to 2/28/2025. LVN 1 stated, there was a total of 15 doses in the bubble pack and eight tablets were still in the bubble pack. LVN 1 stated there were three (3) tablets that were not administered. LVN 1 stated when Resident 197's levothyroxine are not administered the resident could have confusion.

During an interview on 2/28/2025 at 8:47 a.m., the Director of Nursing (DON) stated Resident 197's medication should be administered as ordered and are given to treat specific diseases and monitored. The DON stated when medication is not administered it could affect Resident 197's thyroid functioning. The DON stated LVN 1 should call the doctor and family/representative informing them of what happened. The DON stated if the doctor will order a thyroid test the licensed nurse will carry out the order and monitor the resident for any changes. The DON stated this is a medication error and entails a change in condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a review of the facility's policy and procedure (P&P) titled, Medication Errors, last reviewed on 12/3/2024, the P&P indicated a medication error is The observed or identified preparation or administration Level of Harm - Minimal harm or of medications or biologicals which is not in accordance with: a. The prescriber's order . Procedure: 1. When potential for actual harm a medication reaches a resident in error, the facility should . b. Notify the resident's representative and the Physician/Prescriber to obtain further instructions and/or orders. c. Facility staff should monitor the resident Residents Affected - Some in accordance with Physician's/Prescriber's instructions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 43988 potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary services to Residents Affected - Few maintain good grooming and personal hygiene for one (1) of 1 sampled resident (Resident 65) reviewed for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) by failing to provide proper perineal (involves cleaning the private areas of a resident) care to the resident per facility policy and procedure (P&P).

This deficient practice had the potential to result in a negative impact on Resident 65's psychosocial wellbeing.

Cross-reference

F-F880.

Findings:

During a review of Resident 65 ' s Admission Record, the Admission Record indicated the facility originally admitted the resident on 2/8/2021 and readmitted in the facility on 1/10/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin (a hormone that removes excess sugar from the blood, can be produced by

the body or given artificially via medication), and generalized muscle weakness.

During a review of Resident 65 ' s History and Physical (H&P), dated 1/11/2025, the H&P indicated Resident 65 had the capacity to understand and make decisions.

During a review of Resident 65 ' s Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025,

the MDS indicated Resident 65 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with toileting hygiene, bathing, and lower body dressing; substantial/maximal assistance from staff with all other ADLs.

During a review of Resident 65 ' s Order Summary Report, dated 1/13/2025, the Order Summary Report indicated a physician ' s order for:

Norco Tablet 5-325 MG (hydrocodone- acetaminophen - a type of strong combination of pain medication that contains a narcotic to manage moderate to severe pain) give 1 tablet by mouth every six (6) hours as needed for moderate scale of four (4) to 6 out of 10 to severe pain seven (7) to 10 out of 10 not to exceed three (3) grams (gm - a unit of measurement) of total acetaminophen per day. Hold for sedation and or respiratory rate (RR) of less than12.

During a review of Resident 65 ' s care plan (CP) on risk for pain, initiated on 1/12/2025 and last revised on 1/24/2025, the CP indicated to administer pain medication as ordered, anticipate resident ' s need for pain relief and respond immediately to any complaint of pain, keep resident in comfortable position, monitor or document for probable cause of each pain episode, and remove or limit causes where possible as a few of

the interventions to prevent Resident 65 ' s interruption in normal activities due to pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 During a concurrent observation and interview, on 2/24/2025, at 10:27 a.m., inside Resident 65 ' s room, with CNA 1, CNA 1 provided ADL care to Resident 65. Resident 65 verbalized pain with slight pulling of the left Level of Harm - Minimal harm or leg while CNA 1 placed a sock on Resident 65 ' s left foot. Resident 65 pointed to her left foot and stated she potential for actual harm had a lot of pain on the toes. CNA 1 proceeded to place the sock again on the left foot and Resident 65 complained of pain again by screaming and pulling her left leg and telling CNA 1 not to touch her leg. CNA 1 Residents Affected - Few stated she was trying to put the socks on Resident 65, complete her task, and notify the Charge Nurse (CN) after. CNA 1 stated when residents complain of pain or refusing to continue with ADL care, the staff should notify the CN. 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. CNA 1 stated if the pain was not addressed Resident 65 will continue to refuse ADL care.

During an interview, on 2/24/2025, at 10:35 a.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated 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. LVN 9 stated CNA 1 should have stopped and not attempt to place Resident 65 ' s sock

on the left foot the second time and notified the CN to administer pain medication timely to prevent continued refusal of care and lead to decline in functioning.

During an interview, on 2/28/2025, at 1:00 p.m., with the Director of Nursing (DON), the DON stated when a resident verbalizes pain during ADL care, the CNA should stop providing care, ask the resident the location of the pain, how much pain the resident is having, and notify the CN to address resident ' s pain. The DON stated CNA 1 should have not attempted to place Resident 65 ' s sock on the left foot again when the resident initially complained of pain. The DON stated CNA 1 should have stopped providing care to Resident 65 and notified the CN to address the pain timely. The DON stated 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.

During a review of the facility ' s policy and procedure (P&P) titled, Pain Management, last reviewed on 12/3/2024, the P&P indicated the following:

Recognizing Pain:

1. Observe the resident (during rest and movement) for physiologic and behavioral (nonverbal) signs of pain.

2. Possible Behavioral Signs of Pain:

a. Verbal expressions such as groaning, crying, screaming;

b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.;

c. Changes in gait, skin color and vital signs;

d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 e. Limitations in his or her level of activity due to the presence of pain;

Level of Harm - Minimal harm or 3. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain and potential for actual harm use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994

Residents Affected - Some Based on observation interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to:

1. Accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents 87 and 93 in two of four inspected medication carts on Station 2 Cart 1 and Station 3 Cart 1.

This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Residents 87 and 93 could have received too much or too little medication due to a lack of documentation possibly resulting in serious health complications requiring hospitalization .

2. Administer alprazolam (a medication to treat anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]) for one of three sampled residents (Resident 347) reviewed during the Behavioral- Emotional care area, when Resident 347 requested medication on 2/24/2025 at 6 a.m.

This deficient practice resulted in Resident 347 reporting continued feelings of anxiousness on 2/24/2025 at 10 a.m. and had the potential to result in increased anxiety and risk for a decline in the resident's psychosocial wellbeing.

3. Administer Resident 197's three doses of levothyroxine (used to treat hypothyroidism [a condition where

the thyroid gland does not produce enough thyroid hormone]) as ordered when a discrepancy of three doses of levothyroxine were observed in the bubble pack.

This deficient practice had the potential to result in Resident 197's fluctuations in thyroid hormone levels, leading to symptoms of hypothyroidism such as fatigue, cold intolerance, and constipation.

Findings:

1. a. During a review of Resident 87's Admission Record (a document containing a resident's diagnostic and demographic information), dated 2/27/2025, the Admission Record indicated she was admitted to the facility

on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including seizures (sudden, uncontrolled burst of electrical activity in the brain that can cause changes in movement, behavior, feelings, or awareness).

During a review of Resident 87's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 2/18/2025, the H&P indicated her cognition was poor but did not indicate whether she had the capacity to understand and make decisions or not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of Resident 87's Physician Order Summary (a monthly summary of all active physician orders), dated 2/27/2025, the Physician Order Summary indicated Resident 87 was prescribed clonazepam Level of Harm - Minimal harm or ODT (a controlled medication used to treat seizures) 0.5 milligrams (mg - a unit of measure for mass) by potential for actual harm mouth three times daily for seizure management on 2/22/2025.

Residents Affected - Some During an observation of Station 2 Cart 1 on 2/25/2025 at 1:40 p.m. and concurrent interview with Licensed Vocational Nurse (LVN 4), the following discrepancies were found between the Drug Control Receipt Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and

the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) or physical inventory:

1. Resident 87's Drug Control Receipt Record for clonazepam ODT 0.5 mg indicated there were six doses left, however, the physical inventory contained five doses.

LVN 4 stated she administered the missing dose of clonazepam to Resident 87 around 10 a.m. that day. LVN 4 stated she understands that she needs to sign out the doses of controlled medication on the Drug Control Receipt Record immediately after the medication is removed from the bubble pack or supply. LVN 4 stated she failed to sign for the missing dose earlier because she was distracted by other tasks and did not remember to do it when she returned. LVN 4 stated it is important to maintain accountability of controlled substances to prevent diversion or accidental overdose to the resident. LVN 4 stated if Resident 87 received clonazepam more often than prescribed, it could cause medical complications possibly leading to hospitalization .

1.b. During a review of Resident 93's Admission Record, dated 2/27/2025, the Admission Record indicated

she was admitted to the facility on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including seizures.

During review of Resident 93's H&P dated 10/26/2024, the H&P indicated she had the capacity to understand and make decisions.

During a review of Resident 93's Physician Order Summary, dated 2/27/2025, the Order Summary Report indicated she was prescribed lorazepam (a controlled medications used to treat seizures) 1.5 mg (as one and one-half 1 mg tablets) via gastrostomy tube (g-tube - a tube surgically implanted into the stomach for administration of medications and nutrition) once daily on Tuesday, Thursday, and Saturday for anxiety manifested by repetitive anxious complaints on 2/5/2025.

During an observation of Station 3 Cart 1 on 2/25/2025 at 1:59 p.m. and a concurrent interview with LVN 3,

the following discrepancies were found between the Drug Control Receipt Record and the medication card or physical inventory:

1. Resident 93's Drug Control Receipt Record for lorazepam 1 mg tablets indicated there were 12 doses left, however, the medication card contained 11 doses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 LVN 3 stated she gave the missing medication to Resident 93 at approximately 1:07 p.m. that day. LVN 3 stated she was supposed to sign the dose out on the Drug Control Receipt Record immediately before it was Level of Harm - Minimal harm or administered to the resident. LVN 3 stated she failed to sign it because she forgot. LVN 3 stated signing the potential for actual harm 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. LVN 3 stated if Resident 93 received lorazepam Residents Affected - Some more often than prescribed, it could cause additional drowsiness or other adverse effects which could negatively impact her health or well-being.

During a review of the facility's policy and procedures (P&P) titled Controlled Substances, revised April 2018,

the P&P indicated Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following on the accountability record . date and time of administration . initials of nurse administering the dose, and completed after the medication is actually administered .

44244

2. During a review of Resident 347's Admission Record, the Admission Record indicated the facility admitted

the resident on 2/21/2025 with diagnoses that included generalized anxiety, depressive disorder (depression - persistent feelings of sadness and loss of interest that can interfere with daily living), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when

the kidney(s) have failed).

During a review of Resident 347's H&P, dated 2/28/2025, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 347's Order Summary Report, dated 2/26/2025, the Order Summary Report indicated an order to administer alprazolam oral tablet 0.5 milligrams (mg - a unit of measurement), one tablet by mouth every six hours, as needed for anxiety manifested by physical movements of restlessness for 14 days.

During a review of Resident 347's Care Plan (CP) titled, (Resident 347) is on alprazolam . initiated on 2/22/2025, the CP indicated a goal that the anti-anxiety medication would be effective with an intervention to give medication as ordered by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a concurrent observation, interview, and record review on 2/24/2025 at 10 a.m. with LVN 6, LVN 6 reviewed Resident 347's Medication Administration Record (MAR - - a record of all medications taken by a Level of Harm - Minimal harm or resident on a day-to-day basis) and Progress Notes. Resident 347 was observed lying in bed and stated she potential for actual harm was newly admitted to the facility. Resident 347 stated she felt anxious and had requested medication at 6 a. m. and never saw the nurse again. Resident 347 was observed to activate the call light (an alerting device Residents Affected - Some for nurses or other nursing personnel to assist a patient when in need). LVN 6 entered Resident 347's room and Resident 347 stated Oh, there you are, I haven't seen you all morning. Resident 347 stated she felt anxious and depressed and did not receive the medication she requested at 6 a.m. LVN 6 stated she arrived early to work while the night shift nurse was still providing care to Resident 347. LVN 6 stated Resident 347 had requested alprazolam at 6 a.m. and she notified Licensed Vocational Nurse 7 (LVN 7) to give the medication. LVN 6 reviewed the MAR and noted alprazolam was not administered on 2/24/2025. LVN 6 stated alprazolam was a medication that was ordered to be given as needed and the resident should have received the medication as soon as possible upon the resident's request, but she did not. LVN 6 stated she would give the resident the alprazolam.

During an interview on 2/25/2025 at 6:06 a.m. with LVN 7, LVN 7 stated the usual process for the administration, of as needed medication, is the nurse will be notified that the resident is requesting the medication. The nurse will assess the resident as soon as possible, and the medication will be administered at that time. LVN 7 stated on 2/24/2025 she did not assess Resident 347 for the need for alprazolam and she did not administer alprazolam to the resident. LVN 7 stated on 2/24/2025 she thought LVN 6 was going to give Resident 347 the alprazolam, so she did not administer it. LVN 7 stated 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 (episodes of intense anxiety that lead to severe cognitive, emotional, and physical symptoms) with feelings of stress, fear, and impending doom.

During a concurrent interview and record review on 2/28/2025, at 11 a.m. with the Director of Nursing (DON),

the DON reviewed the facility policy and procedure regarding medication administration. The DON stated when a resident requests an as needed medication, the nurse should assess the resident and provide interventions at that time. The DON stated if the resident required medication, then the nurse should administer the medication. The DON stated Resident 347 should have been assessed and administered alprazolam when the resident requested the medication, but she was not. The DON stated 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. The DON stated the facility policy was not followed when Resident 347 was not delivered the alprazolam when it was requested.

During a review of the facility P&P titled, Administering Medications, last reviewed on 12/3/2025, the P&P indicated the purpose of the policy was 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of the facility's P&P titled, Medication Errors, last reviewed on 12/3/2025, the P&P indicated

the facility ensures that its residents are free of any significant medication errors. A medication error is the Level of Harm - Minimal harm or observed or identified preparation or administration of medications or biologicals which is not in accordance potential for actual harm with accepted professional standards and principles which apply to professionals providing services. A delivery error is a drug product not received by the resident at the expected time. Residents Affected - Some 38552

3. During a review of Resident 197's Admission Record, the Admission Record indicated the resident was admitted on [DATE REDACTED] with diagnoses including presence of left artificial hip joint, hypertensive heart disease (high blood pressure), and hypothyroidism.

During a review of Resident 197's H&P, dated 2/18/2025, the H & P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 197's physician order, dated 2/17/2025, the physician's order indicated levothyroxine sodium oral tablet 75 micrograms (mcg-a unit of measurement) give one tablet by mouth one time a day for hypothyroidism.

During a review of Resident 197's Care Plan Report, dated 2/18/2025, the Care Plan Report indicated the resident has hypothyroidism and required daily thyroid replacement. The Care Plan Report included interventions to administer thyroid replacement therapy as ordered and to monitor or document for side effects and effectiveness done by the licensed nurses.

During an interview on 2/24/2025 at 10:18 a.m. with Resident 197, Resident 197 stated she has been here since 2/17/2025 and she has only received her thyroid medication only two to three times this week. Resident 197 stated she has not received her thyroid medication this morning.

During a concurrent observation and interview on 2/27/2025 at 6:23 a.m. with LVN 1, while in Nursing Station 1, Resident 197's levothyroxine bubble pack was inside the medication cart. LVN 1 stated the levothyroxine 75 mcg tablet bubble pack was filled on 2/17/2025 with a total of five (5) doses/tablets which were administered. LVN 1 stated he has not administered today's dose yet because Resident 197 preferred to receive it at 7 a.m.

During a concurrent interview and record review on 2/28/2025 at 7:17 a.m. with LVN 1, Resident 197's Medication Administration Record (MAR), dated 2/1/2025 - 2/28/2025 was reviewed. The MAR indicated, a total of 10 doses of levothyroxine were administered from 2/18/2025 to 2/28/2025. LVN 1 stated, there was a total of 15 doses in the bubble pack and eight tablets were still in the bubble pack. LVN 1 stated there were three (3) tablets that were not administered. LVN 1 stated when Resident 197's levothyroxine are not administered the resident could have confusion.

During an interview on 2/28/2025 at 8:47 a.m., with the DON, the DON stated Resident 197's medication should be administered as ordered and is given to treat specific diseases and be monitored. The DON stated when medication is not administered it could affect Resident 197's thyroid functioning and the resident should be monitored for any changes. The DON stated LVN 1 should call the doctor and family/representative informing them of what happened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of the facility's P&P titled, Administering Medications, last reviewed on 12/3/2025, the P&P indicated the purpose of the policy was to provide employees with guidelines for the safe and timely Level of Harm - Minimal harm or administration of medications per the physician order. Medications must be administered in accordance with potential for actual harm the orders.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 92 555904 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555904 B. Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994

Residents Affected - Some Based on interview and record review, the facility failed to:

1. Respond to the consultant pharmacist's (a medical professional responsible for a monthly review of all residents' medication regimens) recommendation from 11/30/2024 to limit the duration of PRN (as needed) lorazepam (a medication used to treat mental illness) to 14 days or define a specific length of therapy for one of five residents sampled for unnecessary medications (Resident 101).

2. Respond to the consultant pharmacist's recommendation from 12/31/2024 to define the length of therapy with guaifenesin oral liquid (a medication used to treat cough/congestion) for one of five residents sampled for unnecessary medications (Resident 101).

The deficient practice of failing to ensure the facility responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen

Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 101 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status.

Cross-referenced