The Ellison John Transitional Care Center
THE ELLISON JOHN TRANSITIONAL CARE CENTER in LANCASTER, CA — inspection on December 30, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's MAR note dated 12/2/2025 at 8:34 p.m., the MAR note indicated medication not found.
Reordered.
During an interview on 12/30/2025 at 4:23p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated LVN 2 recalls Resident 1 was suspected to have scabies and was placed on isolation. LVN 2 stated LVN 2 thinks there was an order for scabies cream for Resident 1 but there was no cream. LVN 2 stated she reordered the cream.
During a record review and interview on 12/30/2025 at 4:40 p.m. of Resident 1's Order Summary Report with the Director of Nursing (DON), the DON reviewed Resident 1's Order Summary Report and stated permethrin was ordered twice and was given on 11/25/2025.
The DON stated at the time of the second dose, the Infection Preventionist (IP) had not gotten the second tube, then LVN 2 reordered the medication.
The DON stated the medication was delivered but Resident 1 had been discharged home.
The DON stated the doctor agreed to let Resident 1 go home because Resident 1 was negative for scabies and had already gotten the first treatment and could get the other treatment at home.
The DON stated if the residents order is disrupted and does not receive the treatment as ordered by the doctor, the resident did not complete the treatment.
The DON stated the facility should have the treatment if it was ordered.
The DON stated if Resident 1 did not get the second dose and did have scabies the treatment would not be completed and there is a potential for the scabies not to be eradicated.
During a review of the Facility Policy and Procedure (P&P) titled, Medication Administration-General Guidelines, last reviewed on 12/10/2025, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices.B.
Administration 2.
Medications are administered in accordance with written orders of the attending physician.10.
Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes.
Unless otherwise specified by the prescriber, routine medication are administered according to the established medication administration schedule for the facility.
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