The Ellison John Transitional Care Center

F 0656

the facility interdisciplinary team including the resident and resident representative, if applicable.

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

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

Event ID:

Facility ID:

If continuation sheet

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

12/01/2025

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 0684

information in accordance with facility policy and professional standards of practice.

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

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

Event ID:

Facility ID:

If continuation sheet

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

12/01/2025

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

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

2's Care Plan, initiated on 10/29/2025, the Care Plan indicated Resident 2 was receiving antibiotic therapy for left lower leg cellulitis. The Care Plan interventions indicated to administer medications as ordered.

During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had intact cognitive functioning. The MDS indicated Resident 2 required maximal assistance from the facility staff for personal hygiene, showers, and lower body dressing. During a review of Resident 2's Order Summary Report, the report indicated the following physician's order: -10/28/2025: Ertapenem Sodium Injection Solution reconstituted 1 gram (GM-unit of measurement). Use one gram intravenously in the morning for left leg cellulitis for 14 days. During a concurrent interview and record review on 12/1/2025 at 11:34 a.m. with the Infection Preventionist (IP), Resident 2's Medication Administration Record (MAR), dated 11/2025 was reviewed. The MAR indicated, on 11/7/25 and 11/7/2025, for the 9 p.m. administration time, there were no licensed staff initials in the box for Resident e's Ertapenem Sodium Injection Solution to demonstrate the medication was administered. The IP stated it was important to complete the correct course of antibiotics treatment as ordered by the physician. The IP stated failure to complete the correct dose of antibiotics treatment had the potential for Resident 2 to require extended course of antibiotic treatment due to unresolved infection. During an interview on 12/1/2025 at 3:20 p.m. with the DON, the DON stated Resident 2's disruption of antibiotic therapy had the potential for Resident 2 to develop resistance to antibiotics (when bacteria evolve to become unaffected by antibiotics, making infections harder to treat) requiring more potent antibiotic treatment. During a review of the facility-provided policy and procedure (P&P) titled, Medication Errors, last revised on 12/3/2024, the P&P indicated, The facility ensures that its residents are free of any significant medication errors. Medication Error: The observed or identified preparation or administration of medications or biologicals which is not in accordance with: a. The prescriber's order. 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.

Administration Errors.d. Route error: Facility administers to the resident a medication dose by a route other than that ordered by Physician/Prescriber or a wrong site of administration. During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last revised on 12/3/2024,

the P&P indicated, Medications must be administered in accordance with the orders. Medications must be administered in accordance with state and federal guidelines.

Event ID:

Facility ID:

If continuation sheet

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

12/01/2025

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 0770 Level of Harm - Minimal harm or potential for actual harm

indicated, 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. IV. Surveillance:

The Licensed Nurse will notify the attending physician to determine the treatment plan, including, but not limited to, laboratory tests, special precautions, and other interventions.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

12/01/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 2) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 2's peripheral intravenous catheter (PIV catheter- a thin, flexible plastic tube inserted into a vein to deliver fluids, medications, blood, or nutrition, using a needle for placement that is then removed, leaving just the tube) removal and placement procedures were documented. These deficient practices had the potential for inaccurate medical interventions for Resident 2. Findings: During a review of Resident ‘2s admission Record, the admission

Record indicated the facility admitted Resident 2 on 10/28/2025, with diagnoses including cellulitis of lower extremity (a bacterial skin infection, typically presenting as a red, swollen, warm, tender, and painful area

on the leg requiring prompt antibiotic treatment to prevent serious complications), malignant neoplasm of colon (a cancerous tumor that develops in the colon lining and can spread to other parts of the body), and heart failure (a condition where the heart cannot pump enough blood to meet the body's needs, causing symptoms like fatigue, shortness of breath, and swelling). During a review of Resident 2's Admit/Readmit Evaluation form, dated 10/28/2025, the form indicated the facility admitted Resident 2 with right antecubital (AC-the region at the front, or inner crook, of the elbow, forming a triangular depression known as the antecubital fossa) PIV. During a review of Resident 2's Minimum Data Set (MDS - resident assessment tool), dated 11/4/2025, the MDS indicated Resident 2 had intact cognitive functioning. The MDS indicated Resident 2 required maximal assistance from the facility staff for personal hygiene, showers, and lower body dressing. During a review of Resident 2's Order Summary Report, the report indicated the following physician's order: -10/28/2025: IV peripheral active therapy orders: Start IV, change site every 72 hours and as needed for infiltration (occurs when an IV's non-irritating fluid leaks from the vein into the surrounding skin, causing swelling, coolness, pain, or numbness, and can happen if the catheter slips or the vein is fragile) or soiling. May extend beyond 72 hours due to poor venous access. During a concurrent interview and record review on 12/1/2025 at 10:36 a.m. with Licensed Vocational Nuse (LVN) 1, Resident 2's Progress Notes dated 11/6/2025 and 11/12/2025 were reviewed. The Progress Note dated 11/6/2025 indicated Resident 2 did not have a PIV catheter. The Progress Note dated 11/12/2025 indicated Resident 2's left forearm PIV catheter was removed. LVN 1 stated there was no record to indicate when and why Resident 2's right AC PIV was removed. LVN 1 stated there was no record to indicate when Resident 2's left forearm PIV catheter was placed. During an interview on 12/1/2025 at 3:20 p.m. with the Director of Nursing (DON), the DON stated facility staff should have assessed and documented the reason Resident 2's initial PIV catheter was dislodged or removed. The DON stated the facility staff should have documented when Resident 2's new PIV catheter was placed, where it was placed to monitor for possible complications.

The DON stated the failure to accurately document PIC catheter removal and placement had the potential for delay of care and monitoring of Resident 2 for potential PIV complications. During a review of the facility-provided policy and procedure (P&P) titled, Catheter Insertion and Care, last revised on 12/3/2024,

the P&P indicated, The following information should be recorded in the resident's medical record: 1. The date and time of the procedure. 2. The number of venipuncture attempts (maximum of two). 4. The site of insertion (be specific to name of vein, area of arm).8. The condition of the IV site. 9. Notification of the Physician (if any complications). Reporting: Notify the Supervisor if the resident refuses the procedure or if procedure is unsuccessful. 2. Report other information in accordance with facility policy and professional standards of practice.

Event ID:

Facility ID:

If continuation sheet