The Ellison John Transitional Care Center

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