The Ellison John Transitional Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/11/2025 at 2:30 p.m., ADON stated, Registered Nurse (RN 2) needed to call Resident 1's Medical Doctor to notify of Resident 1's change of condition immediately. ADON stated, there was a delay in care and treatment of Resident 1. ADON stated, the facility should have called the Medical Doctor to obtain orders for Resident 1. ADON stated, it should not have taken two days to respond to Resident 1's right facial numbness. During a record review of the facility's Policy and Procedure titled, Notification of Changes dated November 2017, indicated the facility informs the resident's physician, and resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status in either life-threatening condition of clinical complications. The Attending Physician will be notified timely with a resident's change in condition.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of three sampled residents (Resident 8) by failing to ensure the resident's medications were not left unattended at bedside. This deficient practice had the potential to cause medication errors and could possibly lead to Resident 8's discomfort.Findings: During a review of Resident 8's admission Record (undated), the admission Record indicated the facility admitted the resident on 9/8/2025 with diagnoses that included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). During a review of Resident 8's Physician Order, dated 9/8/2025, the Physician Order indicated polyethylene glycol 3350 powder (a medication used to relieve constipation) 17 grams (unit of measurement) mixed with eight ounces (oz - unit of measurement) of water, one time a day for bowel management. During a review of Resident 8's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/9/2025, the H&P indicated Resident 8 had the capacity to understand and make decisions. During a concurrent observation and interview on 9/10/2025 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 2, observed LVN 2 left Resident 8's room and went to the nurse station. LVN 2 left Resident 8's water mixed with polyethylene glycol 3350 powder on the bedside table unattended. LVN 2 returned to Resident 8's room and stood at the door. LVN 2 stated she gave all of Resident 8's scheduled medications and was going to document the medications as given. The surveyor clarified with LVN 2 if Resident 8's scheduled medications were administered and LVN 2 stated she gave all of Resident 8's scheduled medications. LVN 2 looked in Resident 8's room and stated that she forgot to give the resident's water mixed with polyethylene glycol 3350 powder. LVN 2 stated that she should not leave medications unattended. LVN 2 stated that medications left unattended had the potential for other residents to take the medications or for Resident 8 to not take the medication and result in discomfort and constipation. During an interview on 9/10/2025 at 3:03 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 8's medication should not be left unattended. RN 1 stated other residents had the potential to drink Resident 8's medication on the bedside table thinking it was regular water. RN 1 stated the facility failed to ensure Resident 8's medication was not left unattended and failed to ensure Resident 8 received all the scheduled medications before leaving the resident's room. During a review of the facility's policy and procedure (PnP) titled, Administering Medications, last reviewed on 12/3/2024, the PnP indicated the purpose to provide employees with guidelines for the safe and timely administration of medications per physician order. The PnP indicated following verification of the resident and scheduled medication, the licensed nurse follows the pour, pass, chart standard of practice.

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