The Ellison John Transitional Care Center

During a review of the facility ' s P&P titled, Homelike Environment, last reviewed on 12/3/2024, the P&P indicated: The facility strives to provide a personalized, homelike environment which recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members.

The facility environment should enhance the quality of life for residents in accordance with resident preferences.

It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

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

warranted.

• The licensed nurse shall obtain a physician's order for the use and specific type of restraint.
• The interdisciplinary team shall complete a physical restraint assessment to identify potential risks

associated with the restraint use, specific to the resident.

• The interdisciplinary team will complete a resident centered care plan, based on the restraint

assessment with individualized interventions for care.

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

Summary, last reviewed 12/3/2024, the P&P indicated the Discharge Assessment - return not

minimal harm days and Transmission Date No Later Than MDS Completion Date +14 calendar days.

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

During an interview on 2/28/2025, at 9:22 a.m., with the Director of Nursing (DON), the DON stated the Resident 29's MDS dated [DATE] should have been coded that the resident was using a home CPAP while at the facility to reflect the accurate picture of the resident for care planning.

The DON stated even though the MDSN 2 did not see the home CPAP, the staff should have reported it to MDSN 2 to update the MDS Assessment.

The DON stated providing an accurate assessment of the resident can help provide appropriate and relevant care to the resident.

During a review of the facility's recent P&P titled Resident Assessment, last reviewed on 12/3/2024, the P&P indicated the facility uses the Resident Assessment Instrument (RAI, is a tool used in nursing homes to assess residents' needs and strengths) in accordance with special format and timeframes as set forth by Centers for Medicare & Medicaid Services (CMS, a federal agency that administers major healthcare programs).

The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

Using the RAI provided by CMS, the facility develops a comprehensive assessment of a resident's needs, strengths, goals, life history and preference.

The assessment minimally includes the following: -Special treatments and procedures.

During a review of the facility's recent P&P titled Accuracy of Assessments, last reviewed on 12/3/2024, the P&P indicated the facility ensures each resident receives accurate assessment, reflective of the resident's status at the times of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline.

• During a review of Resident 104's admission Record, the admission Record indicated the resident

was admitted on [DATE] with diagnoses including anoxic brain injury (caused by a complete lack of oxygen to the brain), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia, and essential (primary) hypertension (high blood pressure).

During a review of Resident 104's physician progress note, dated 2/2/2025, the physician progress note indicated the resident does not have the capacity to make decisions.

During a concurrent interview and record review on 2/27/2025 at 3:05 p.m. with MDSN 2, reviewed Resident 104's MDS Assessments Section A0500 Question History. MDSN 2 stated Resident 104's last name on the MDS Assessments Section A0500 Question History did not match the resident's Medicaid insurance card for the following assessments:

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

F 0641 -

minimal harm -

1/29/2024, Comprehensive Assessment - 7/24/2024, Quarterly Assessment - 10/17/2024, Quarterly Assessment - 4/30/2024, Quarterly Assessment During an interview on 2/28/2025 at 9:01 a.m. with the DON, the DON stated resident's legal name should be entered correctly because they are ensuring right services to the right person and the identified person in that billing is accurate.

During a concurrent interview and record review on 2/28/2025 10:16 a.m., reviewed the CMS Long-Term Care Facility RAI 3.0 User's Manual, dated 10/2024, with MDSN 1. MDSN 1 stated the RAI manual indicated the Resident's name as it appears on the Medicare card. If the resident is not enrolled in the Medicare program, use the resident's name as it appears on a Medicaid card or other government-issued document. MDSN 1 stated they will submit an MDS modification assessment to reflect the resident's legal name according to the RAI manual.

During a review of the facility's recent P&P titled Accuracy of Assessments, last reviewed on 12/3/2024, the P&P indicated the facility ensures each resident receives accurate assessment, reflective of the resident's status at the times of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline.

During a review of the facility's policy and procedures (P&P) titled Baseline Care Plan, revised March 2023, the P&P indicated The facility develops and implements a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards and quality of care .

The baseline care plan is based on the resident's admission orders, information available from the transferring provider, and discussion with the resident and resident representative, if available.

Each resident's baseline care plan includes the instructions needed to provide effective and person-centered care for the immediate needs of the resident that meet professional standards of care .

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

During an interview on 2/27/2025 at 8:04 a.m., with Resident 97, Resident 97 lay in bed and stated

her care because she was afraid of men cleaning her.

During a concurrent interview and record review on 2/27/2025 at 8:56 a.m., with the DSD, the DSD reviewed Resident 97's care plans.

The DSD stated the DSD had known for about a year that Resident 97 did not want any male CNA's providing the resident's care.

The DSD stated the DSD did not document or develop a care plan for Resident 97's preference for no male CNAs.

During a concurrent interview and record review on 2/27/2025 at 8:56 a.m., with Minimum Data Set Nurse (MDSN) 2, MDSN 2 reviewed Resident 97's care plans and physician orders. MDSN 2 stated care plans are individualized for specific resident needs. MDSN 2 stated when a resident verbalizes a preference for no male CNAs to be assigned to provide care, there should be a care plan to reflect the preference to ensure that all facility staff are aware of the resident's preferences. MDSN 2 stated it was important to develop a CP for Resident 97's preference for no male CNAs to ensure no male CNAs were assigned to care for Resident 97.

During a concurrent interview and record review on 2/27/2025 at 9:10 a.m., with the DON, the DON reviewed Resident 97's CPs and facility policy regarding CPs.

The DON stated she was not aware Resident 97 had a preference for no male CNAs to be assigned to provide care.

The DON stated when Resident 97 verbalized a preference for only female CNAs, a CP should have been created but it was not.

The DON stated the importance of CPs is a CP communicates with the interdisciplinary team the resident preferences to make sure the plan for the resident's care is what the resident wants.

The DON stated when a CP for Resident 97's preference was not developed there was a potential that things could fall through the cracks and the needs of the resident would not be met.

During a review of the facility recent P&P, last reviewed 12/3/2024, the P&P indicated the facility develops person-centered comprehensive care plans that are culturally competent and trauma-informed, developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Person-Centered Care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.

The comprehensive care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Care plans must be person-centered and reflect the resident's goals for admission and desired outcomes, interventions that reflect the resident's cultural preferences, values and practices.

The interdisciplinary team develops the care plan with corresponding interventions for care that is in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause retraumatization of the resident.

The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.

Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences.

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

to determine if they need care planning). CAAs may be used as frequently as indicated for

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

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.

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 of medications or biologicals which is not in accordance with: a.

The prescriber's order .

Procedure: 1.

When 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 in accordance with Physician's/Prescriber's instructions.

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

indicated a purpose to maintain the cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown.

The P&P further indicated the following procedure: Wash hands Explain procedure to resident Prepare equipment: washbasin, soap, washcloths bath towel, bed protector or pad, gloves, overbed table protector Put on gloves Wash the pubic area for female residents: separate the labia (the folds of skin surrounding the vaginal opening).

Wash with soapy washcloth, moving from front to back, on each side of the labia and in the using a clean area of the washcloth for each stroke; rinse the area moving from front to back using a clean of the washcloth for each stroke; dry the area moving from front to back using a blotting motion with towel Do not touch anything with soiled gloves after procedure such as curtain, side rails, clean linen, call bell, etc.) Put on clean gloves Clean and return all equipment to its proper place Place soiled linen in proper container Remove gloves Wash hands

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

During an interview on 2/28/2025 at 1:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated he was only made aware today about Resident 197 ' s missed levothyroxine doses.

The ADON stated the licensed nurse, Registered Nurse (RN) or LVN, can initiate the change in condition (COC) and progress notes and this should be done as soon as possible.

The ADON stated an RN would then close the resident ' s COC assessment.

The ADON stated the purpose of initiating a COC and progress notes if to monitor Resident 197 for any adverse consequences.

During a review of the facility ' s policy and procedure (P&P) titled, Care and Services Interdisciplinary Team, last reviewed 12/3/2024, the P&P indicated the licensed nurse/designee documents and notifies the resident ' s physician and responsible party of: Change in condition including progress and/or decline in physical or mental function.

During a review of the facility ' s P&P titled, Medication Errors, last reviewed 12/3/2024, the P&P indicated 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 .

Procedure: 1.

When 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 in accordance with Physician ' s/Prescriber ' s instructions.

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

During an observation on 2/24/2025, at 9:28 a.m., observed Resident 34's fall mat at the right side of the bed had an oxygen concentrator (a medical device that removes nitrogen from the air to deliver oxygen that's 85-95% pure) and a side table on top of them.

During a concurrent observation and interview on 2/24/2025, at 9:39 a.m., with LVN 5, inside Resident 34's room, observed Resident 34's fall mat at the right side of the bed had an oxygen concentrator and a side table on top of them. LVN 5 stated there should be no furniture or medical equipment on top of the fall mat of Resident 34 because the resident can fall on them and cause falls with injury to the resident such as fractures (break in bone) and lacerations (cut refers to a skin ).

During an interview on 2/28/2025, at 9:16 a.m., with the DON, the DON stated the fall mat of Resident 34 should be clear of equipment or furniture on top of them to prevent falls with injury.

The DON stated the resident could hit the medical equipment or furniture on top of the fall mat when they fall that can cause laceration or fracture on residents.

During a review of the facility's recent P&P titled Fall Management Program, last reviewed on 12/3/2024, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to mi[TRUNCATED]

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

During an observation, on 2/26/2025, at 8:30 a.m., inside Resident 53 ' s room, Resident 53 laid in bed

tubing had a loop.

During a concurrent observation and interview, on 2/26/2025, at 8:35 a.m., inside Resident 53 ' s room, with LVN 7, LVN 7 confirmed and stated Resident 53 ' s urinary catheter tubing had a loop, and the loop had urine inside. LVN 7 stated the urinary catheter tubing should not have a loop as the urine will not flow freely, can back up into the bladder and cause UTI. LVN 7 stated Resident 53 ' s urinary catheter tubing should have no loop as it placed Resident 53 at risk for acquiring UTI.

During an interview on 2/28/2025, at 1 p.m., with the DON, the DON stated urinary catheter tubing should be positioned properly on the side of the bed to prevent loop or kink as the urine will not flow freely and go back up into the bladder.

The DON stated the staff should check every time they go to the resident ' s room if the urinary catheter tubing had a loop or kink.

The DON stated Resident 53 ' s urinary catheter drainage bag should have been placed properly on the side of the bed to prevent kink or loop as the urine will not flow freely and back up into the bladder which may lead to UTI.

During a review of the facility ' s P&P titled, Indwelling Catheter Use, last reviewed on 12/3/2024, the P&P indicated the facility monitors residents with catheters for changes in skin integrity, skin irritation or breakdown, and signs and symptoms of urinary tract infection.

During a review of the facility provided clinical guideline titled, Guideline for Prevention of Catheter Associated Urinary Tract Infections, dated 3/25/2024, the clinical guideline indicated to maintain an unobstructed urine flow and to keep the catheter and collecting tube free from kinking as a few of the proper techniques for urinary catheter maintenance.

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

During a review of the facility's recent P&P titled, Infection Prevention and Control Program, last reviewed on 12/3/2024, the P&P indicated to ensure the facility establishes and maintains an infection control program designated 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.

During a review of the facility's recent P&P titled, Develop-Implement Comprehensive Care Plans, last reviewed on 12/3/2024, the P&P indicated the facility develops a person-centered comprehensive care plans that are culturally competent and trauma-informed, developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

During a review of the facility-provided User Manual titled, CPAP 1, undated, the User Manual indicated under Cleaning the Tubing, hand wash the tubing and the mask adaptor (if included) before first use and daily.

For daily cleaning, disconnect the tubing from the device and the mask, and if included, disconnect the mask adaptor from the tubing.

For the flexible tubing, gently wash the tubing and mask adaptor in a solution of warm water and a liquid dish soap.

Rinse thoroughly.

Air dry.

Inspect the tubing and mask adaptor for damage or wear.

Discard and replace if necessary.

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

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:

• Observe the resident (during rest and movement) for physiologic and behavioral (nonverbal) signs

of pain.

• 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; e.

Limitations in his or her level of activity due to the presence of pain;

• Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term pain

and use other descriptors such as throbbing, aching, hurting, cramping, numbness or tingling.

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

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.

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 administration of medications per the physician order.

Medications must be administered in accordance with the orders.

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

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 .

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

number of doses or duration of therapy to be given . cough and cold preparations 10 days.

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

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.

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

Information indicated to avoid tissue damage (skin thinning, skin thickening, or skin lumps). always

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.

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

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.

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

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.

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

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.

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

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.

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

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.

555904

Form Approved OMB

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

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.

555904

Form Approved OMB

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

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.

555904

Form Approved OMB

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

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:

555904

Form Approved OMB

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

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.

555904

Form Approved OMB

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