Health inspection·November 12, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following timeline of events on 8/26/2025:- At 9:25 p.m., Companion 1 notified the LVN that Resident 1 had a fall near bedside. The RN assessed Resident 1 and the physician was notified with an order to transfer to the hospital via 911. FM 1 was notified, refused transfer to GACH 1, and requested to wait to call 911 until FM 1 arrived at the facility. - At 9:50 p.m. FM 1 arrived at the facility.-At 9:55 p.m., 911 was called.-At 10:05 p.m., paramedics arrived at the facility. -At 10:25 p.m., Resident 1 was transferred to GACH 1. During a concurrent interview and record review on 11/7/2025 at 1:35 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 1's SBAR COC form dated 8/27/2025, Physician's Orders, H&P dated 8/22/2025, Advance Directive (a legal document indicating resident preference on end-of-life treatment) dated 12/18/2024, and Progress Notes for 8/2025. The MDSC stated the facility process is when a physician or staff determines that 911 should be called, then 911 is called immediately. The MDSC stated on 8/26/2025 at 9:25 p.m. Resident 1 had a fall that resulted in injury to the head and arm, the physician was notified and placed an order to send Resident 1 via 911 to the hospital for possible fracture. The MDSC stated 911 should have been called immediately because there was a doctor's order and it was in the best interest and safety of the resident. The MDSC stated Resident 1's most recent H&P indicated the resident had the capacity to make decisions and there was no documented evidence that Resident 1 refused to transfer via 911. The MDSC stated Resident 1 also had an AD that indicated the resident did not have the capacity to make decisions. The MDSC stated there was a delay of approximately 30 minutes before 911 was called because FM 1 did not want Resident 1 to transfer to GACH 1. The MDSC stated there should not be a delay of calling 911 in an emergency, but if there is a delay, then the physician should be notified of the delay to address the time gap and put interventions in action. The MDSC stated there was no documented evidence that the physician was notified of FM 1's refusal to immediately call 911 on 8/26/2025. The MDSC stated when the physician was not notified, there was the potential for Resident 1 to develop complications like bleeding on the brain. During an interview on 11/7/2025 at 3:11 p.m. with RN 2, RN 2 stated on 8/26/2025 RN 2 assessed Resident 1 in bed and the resident could not move the right arm and had swelling on the left side of the head. RN 2 stated a loss of range of motion in the arm and swelling to the head was very concerning and required a 911 transfer to the nearest hospital which was GACH 1. RN 2 stated RN 2 called FM 1 to report the need for a 911 transfer to GACH 1. RN 2 stated FM 1 told RN 2 not to send Resident 1 to GACH 1 and to wait until FM 1 arrived at the facility to call 911. RN 2 stated FM 1 wanted the resident sent to GACH 2 because FM 1 believed GACH 1 was not safe. RN 2 stated RN 2 was concerned to not immediately call 911, but FM 1 was very forceful and RN 2 could not think because FM 1 was screaming. RN 2 stated RN 2 waited to call 911 until FM 1 arrived at the facility. RN 2 stated there was a delay in calling 911 for Resident 1. RN 2 stated a delay in calling 911 could potentially be dangerous and result in complications like internal bleeding in Resident 1. RN 2 stated when a physician order to transfer 911 is refused or treatment is delayed, the physician should be notified to make a decision regarding the delay. RN 2 stated RN 2 did not notify the physician, but RN 2 should have. During a concurrent interview and record review on 11/12/2025 at 9:23 a.m. with the Director of Nursing (DON), the DON reviewed the facility Policy and Procedures (P&P) regarding physician notification and emergency services. The DON stated the facility process when a resident or responsible party refuses care or there is a need to significantly alter treatment, is to notify the physician because the physician determines the resident's treatments. The DON stated Resident 1 needed emergent care after the fall on 8/26/2025. The DON stated when FM 1 refused to allow RN 2 to call 911, the physician should have been notified that FM 1 wanted Resident 1 transferred to GACH 2. The DON stated the DON was made aware by RN 2 that RN 2 did not notify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 2 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete physician. The DON stated the facility P&P was not followed when Resident 1's physician was not notified of the delay in calling 911 potentially resulting in a delay of care when a drastic change occurred in the resident. During a review of the facility P&P titled, Notification of Changes, last reviewed 12/3/2024, the P&P indicated, The facility informs . the resident's physician. when there is an accident resulting in injury, changes involving life threatening conditions, adverse treatment consequences or transfer or discharge of the resident. DEFINITIONS.A need to alter treatment significantly: A need to stop . or commence a new form of treatment to deal with a problem. GUIDELINES: 1.The facility notifies the physician of . a. An accident involving the resident which results in injury and has the potential for requiring physician intervention; . c. A need to alter treatment significantly . d. A decision to transfer or discharge the resident from the facility. During a review of the facility P&P titled, Emergency Services, last reviewed 12/3/2024, The P&P indicated, The facility provides emergency services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions. During a review of the facility P&P titled, First Aid Treatment, last reviewed 12/3/2024, the P&P indicated, Residents who experience minor injuries shall be treated at the facility. If the injuries cannot be treated with basic Red Cross first aid intervention, the resident will be transferred to the hospital for further treatment. GUIDELINES . 4. In the case of life-threatening injuries or situations, the goal is patient stabilization until the EMS arrives as indicated by the physician when the resident's condition does not respond to the interventions implemented at the facility. 7. In addition to providing basic first aid intervention, contact the emergency medical system (EMS) or advanced medical personnel immediately for the following situations: . k. Suspected head, neck or spine injury. l. Suspected broken bone or open fracture . Event ID: Facility ID: 555904 If continuation sheet Page 3 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an allegation of employee-to-resident abuse to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) as per its policy on abuse for one of five sampled residents (Resident 3). This failure had the potential to place Resident 3 at risk for not having an advocate. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 11/2/2025, with diagnoses including Parkinson Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, affecting the arm, leg, hand, and or face) following cerebral infarction (a condition where brain tissue dies due to a lack of blood supply). During a review of Resident 3's History and Physical (H&P), dated 11/3/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (a resident assessment tool), dated 11/2/2025, the MDS indicated Resident 3 had intact cognition (normal mental abilities that allow someone to effectively handle the day-to-day demands of life). During a review of Resident 3's Situation Background Assessment Recommendation (SBAR, technique that provides a framework for communication between members of the health care team about a resident ' s condition): Change of Condition Form, dated 11/3/2025, the SBAR indicated on 11/3/2025, at 8 p.m., Resident 3 reported to Registered Nurse (RN) 1 that Resident 2 was hit by the certified nursing assistant (CNA, name not indicated) assigned to her at around 3 a.m. while providing hygiene care and repositioning and was assisted by another CNA (name not indicated). The SBAR indicated CNA 3 notified RN 1 and the physician ordered to monitor the vital signs. During a review of Resident 3's Social Services Notes, dated 11/4/2025, the Social Services Notes indicated that Resident 3 did not have visible signs of distress and stated she was fine. The Social Services notes further indicated the alleged incident happened the night before and that two CNAs walked in to change her and proceeded to slap her, but Resident 3 was unable to remember when or where the incident happened and already forgot about the incident until she was asked by Social Services Coordinator (SSC) 1. During an interview on 11/4/2025 at 12:39 p.m. with Registered Nurse (RN) 1, RN 1 stated that Certified Nursing Assistant (CNA) 3 reported to her that Resident 3 Family Member (FM) 1 that 2 CNAs hit her the night that she was admitted to the facility. RN 1 stated for any allegations of abuse, it has to be reported immediately to the Administrator (ADM) and fax a report to the SSA, local law enforcement office, and the Ombudsman. RN 1 stated she reported the incident to the department of public health and local law enforcement within 2 hours, but she forgot to report to the Ombudsman. RN 1 stated she should have reported the allegation of abuse by Resident 3 to the Ombudsman within 2 hours of the alleged incident as it can place Resident 3 at risk for further potential abuse. RN 1 stated the Ombudsman is the advocate for residents in long term care settings to ensure they are safe and getting proper treatment to maintain their quality of life. During an interview on 11/6/2025 at 10:35 a.m., with the Director of Nursing (DON), the DON stated the Ombudsman was not notified by RN 1. The DON stated she is the acting abuse coordinator in the absence of the ADM. The DON stated the facility is supposed to report any allegation of abuse to the SSA, local law enforcement, and the Ombudsman thru a phone call within 2 hours of the incident and followed by a faxed report to the same agencies within 24 hours per facility policy and state and federal regulations. The DON stated the Ombudsman is an advocate for long term care residents to ensure they are safe in the facility, and that they are getting the respect and dignity they deserve to help maintain their quality of life. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 4 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated that RN 1 should have reported Resident 3's allegation of abuse to the Ombudsman within 2 hours thru a phone call and the facility should have faxed the written report within 24 hours as it placed Resident 3 at risk for further potential abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition and Prevention Program, last reviewed on 12/3/2024, the P&P indicated that the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of property, are reported immediately, but no later than 2 hours after the allegation is made, or not later than 24 hours to the administrator of the facility and to other officials including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with the state law through established procedures. Event ID: Facility ID: 555904 If continuation sheet Page 5 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the resident who was repeatedly attempting to get out of bed unassisted, did not fall out of bed and sustained injury for one of four sampled residents (Resident 1). The facility failed to: 1a. Ensure Licensed Vocational Nurse (LVN) 3 responded to Resident 1's family provided caregiver (Companion) 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1b. Ensure LVN 3 notified Registered Nurse (RN) 2 regarding Companion 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1c. Ensure Resident 1's bed's pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was plugged-in and functioning when Resident 1 was attempting to get out of bed unassisted on 8/26/2025. 1d. Ensure LVN 3 and Certified Nursing Assistant (CNA) 3 did not move Resident 1 back to bed without a registered nurse (RN) assessing the resident for safe transfer to bed after Resident 1's fall on 8/26/2025. These deficient practices resulted in Resident 1 having an unwitnessed fall on 8/26/2025 at 9:21 p.m. and was transferred to the General Acute Care Hospital (GACH) for possible fracture (broken bone). At the GACH, Resident 1 was diagnosed with a right angulated (bent), displaced (the bone cracks or breaks and does not retain proper alignment) oblique (slanting or diagonal) fracture of the distal (away from the center of the body) humerus (a severe elbow fracture where the broken bone fragments have shifted out of alignment and are angled) requiring surgery with the placement of metallic hardware (device implanted into the body to provide support), blunt head trauma (injury caused by a sudden impact), and mild left frontal scalp (the skin covering the head) and periorbital (around the eye) soft tissue swelling / hematoma (bruise). 2. Ensure Resident 2's pad alarm was plugged in and functioning. This deficient practice had the potential to result in falls with injury to Resident 2. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included displaced intertrochanteric (a hip fracture that occurs between the greater [large bony prominence on the outer side of the femur {thighbone} and lesser trochanters {smaller projection on the inner side of the femur}, which are bony protrusions {sticks out} on the upper part of the femur) fracture of the left femur, pain, bacterial pneumonia (an infection/inflammation in the lungs), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life) of unspecified severity, age-related osteoporosis (weak and brittle bones), muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/26/2025, the MDS indicated Resident 1 was able to understand others and able to make herself understood. The MDS further indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene and upper body dressing; and substantial/maximal assistance (helper does more than half the effort) with bathing, lower body dressing, toileting, rolling left to right, moving from sitting to lying, and moving lying to sitting on the side of the bed. During a review of Resident 1's Fall Risk Evaluation (FRE), dated 8/19/2025, the FRE indicated the resident had a history of one to two falls in the past three months, had balance problems while standing / walking, was regularly incontinent (having no or insufficient voluntary control over urination or defecation [the discharge of feces from the body]) of unspecified bladder or bowel, and was a high risk for falls. During a review of Resident 1's care plan (CP) titled Risk for fall: Resident is at risk for recurrent falls and spontaneous injuries related to history of falling, muscle weakness, left intertrochanteric fracture due to fall., initiated 8/20/2025, the CP indicated a goal for the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 6 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few to minimize risk of injury from falls. The CP interventions included anticipating and meeting the resident's needs, promoting a safe environment, and that the resident needs activities that minimize the potential for falls while providing diversion and distraction. During a review of Resident 1's CP titled Bed Alarm: Resident is at risk for recurrent fall and spontaneous injury due to impaired safety awareness, cognitive impairment and getting out of bed unassisted, history of fall and poor follow through, initiated 8/19/2025, the CP indicated a goal for Resident 1 was to maintain optimal safety by ensuring the bed alarm is used consistently, and that staff respond appropriately to prevent falls. The CP indicated interventions included to place a functioning bed alarm on Resident 1's bed, ensure the bed alarm was securely attached, and training staff how to properly use the bed alarm. During a review of Resident 1's Physician Orders, the Physician Orders indicated the following: -Place a pad alarm in bed, monitor for placement and function every shift, dated 8/19/2025. - Transfer Resident 1 out via 911 (phone number used to contact the emergency services) due to possible fracture status post fall, dated 8/26/2025. During a review of Resident 1's Post Fall Evaluation / Interdisciplinary Team (IDT- a group of healthcare professionals with various areas of expertise who work together toward the goals of their residents), dated 8/27/2025, the Post Fall Evaluation/IDT document indicated Resident 1 had a previous fall on 8/12/2025, prior to admission to the facility. The Post Fall Evaluation /IDT document indicated on 8/26/2025 at 9:20 p.m. the family-provided companion (Companion 1) exited Resident 1's room to make a phone call. The Post Fall Evaluation/IDT indicated at 9:21 p.m. on 8/26/2025, Resident 1 had an unwitnessed fall inside the resident's room that resulted in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status (did not specify the location). During a review of Family Member (FM) 1's provided Incident Statement - Caregiver Report, dated 8/26/2025, the report indicated on the evening of 8/26/2025 Companion 1 notified facility staff multiple times (did not indicate the exact times) that Resident 1 was repeatedly attempting to get out of bed without assistance. The report indicated Companion 1 called the assigned nurse who confirmed assistance would be sent, but no staff arrived. The report indicated Companion 1 exited the room to call Companion 1's Home Health Care Agency (HHCA) Supervisor (on 8/26/2025) then heard a loud noise from Resident 1's room and discovered Resident 1 had fallen from the bed. During a review of Resident 1's GACH 1's Records, dated 11/18/2025, the GACH 1 Records indicated Resident 1 was admitted to the emergency department on 8/26/2025 at approximately 11 p.m. after a fall with blunt head trauma. Resident 1's diagnostic radiology (x-ray - a medical imaging test that produces images of the structures inside the body) indicated the resident sustained a right angulated, displaced oblique fracture of the distal humerus requiring surgery with the placement of metallic hardware. Resident 1's Computed Tomography (CT - imaging procedure that uses x-rays and digital computer technology to create detailed pictures of the body) indicated the resident sustained a mild left frontal scalp and periorbital soft tissue swelling / hematoma. During an interview on 11/5/2025 at 3:15 p.m. with CNA 3, CNA 3 stated he (CNA 3) was assigned to care for Resident 1 on 8/26/2025 for the evening shift (3 to 11 p.m.) and Resident 1 had a family-provided caregiver at bedside. CNA 3 stated the family-provided caregivers do not provide hands-on care in the facility because the caregivers say it is not their job. CNA 3 stated he (CNA 3) did not know Resident 1 was trying to get out of bed unassisted on 8/26/2025. CNA 3 stated sometime after his (CNA 3) break, the caregiver reported that Resident 1 had a fall and CNA 3 notified LVN 3 and the RN supervisor. CNA 3 stated Resident 1 was found lying face down near the window and there was no bed pad alarm sounding. CNA 3 stated he (CNA 3) assisted with placing Resident 1 back in bed after the fall. CNA 3 stated Resident 1 complained of arm pain when Resident 1 was moved to the bed. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 7 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few 11/6/2025 at 1:02 p.m. with LVN 3, LVN 3 stated he (LVN 3) was assigned to care for Resident 1 on 8/26/2025 during the evening shift. LVN 3 stated prior to admission, Resident 1 had a history of getting up unassisted resulting in a fall with injury. LVN 3 stated Resident 1's family provided Companion 1 to sit with and verbally re-direct the resident and there was a physician's order for a pad (bed) alarm to prevent the resident from getting up unassisted. LVN 3 stated Resident 1 was a little more confused and less redirectable on 8/26/2025. LVN 3 stated at approximately 9 p.m., during Resident 1's medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), he (LVN 3) observed Resident 1 was trying to get out of bed. LVN 3 stated Companion 1 told him (LVN 3) that Resident 1 kept trying to get up unassisted. LVN 3 stated he (LVN 3) told Companion 1 to watch Resident 1 and keep the resident safe. LVN 3 stated that he (LVN 3) also told Companion 1 that he (LVN 3) would provide help to redirect the resident so the resident would not fall. LVN 3 stated he (LVN 3) did not check whether Resident 1's pad alarm was functional during the medication pass but should have because Resident 1 tried to get up unassisted. LVN 3 stated he (LVN 3) then exited Resident 1's room and continued the medication pass for other residents because there was a time deadline to complete the medication pass. LVN 3 stated he (LVN 3) did not notify any staff to assist Companion 1 or that Resident 1 was repeatedly trying to get out of bed unassisted. LVN 3 stated he (LVN 3) should have immediately told the RN on duty that Resident 1 was more agitated and was trying to get up unassisted, but he (LVN 3) did not. LVN 3 stated approximately ten minutes later, when he (LVN 3) was in the hallway, he (LVN 3) observed Companion 1 exited Resident 1's room with a phone and stated Companion 1 was calling Companion 1's HHCA Supervisor because Resident 1 was trying to get up. LVN 3 stated he (LVN 3) did not go to Resident 1's room. LVN 3 stated he (LVN 3) then observed Companion 1 entered and exited Resident 1's room and stated to him (LVN 3) that Resident 1 had fallen. LVN 3 stated he (LVN 3) entered Resident 1's room and observed Resident 1 was on the floor and the bed pad alarm was disconnected (unplugged) and not alarming. LVN 3 stated if the bed pad alarm had been connected and functioning, it may have stopped Resident 1 from getting up and alerted staff to immediately respond to Resident 1's attempt to get out of bed. LVN 3 stated Resident 1's fall was preventable to a certain extent because he (LVN 3) should have checked the pad alarm during the medication pass, immediately notified the assigned CNA (CNA 3) to assist Companion 1, and immediately notified the RN on duty to assess Resident 1. LVN 3 stated that preventing resident falls was the responsibility of facility staff, not family caregivers. During an interview on 11/6/2025 at 3:46 p.m. with HHCA Administrator (Adm), the HHCA Adm stated Resident 1's family hired the HHCA to provide companions to Resident 1. The HHCA Adm stated companions provide conversation with the resident, oversee how the residents are doing and make sure they are getting therapy, and are not medically trained. During an interview on 11/7/2025 at 11 a.m. with the HHCA Supervisor, the HHCA Supervisor stated she (HHCA Supervisor) was Companion 1's Supervisor on 8/26/2025. The HHCA Supervisor stated Companion 1 called her (HHCA Supervisor) three times on 8/26/2025 to notify that Resident 1 was agitated, restless, attempting to get out of bed, and that the facility staff were notified but they were not helping. During an interview on 11/7/2025 at 2 p.m. with RN 2, RN 2 stated when a nurse is made aware that a resident is confused and attempting to get out of bed, the nurse should act right away. RN 2 stated on 8/26/2025 when LVN 3 observed, and was notified by Companion, that Resident 1 was repeatedly trying to get out of bed, LVN 3 should have checked the bed alarm and notified RN 2. RN 2 stated she (RN 2) was not notified that Resident 1 was attempting to get out of bed. During a follow-up interview on 11/7/2025 at 3:11 p.m. with RN 2, RN 2 stated that when a resident has a family-provided companion while in the facility, it is still the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 8 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few responsibility to take care of the residents and provide fall interventions. RN 2 stated the pad alarm alerts staff when the resident moves and also reminds the confused resident to call for help. RN 2 stated a pad alarm should be on when the resident is in bed and should be checked when staff enter the room. RN 2 stated when LVN 3 was aware Resident 1 was attempting to get out of bed, LVN 3 should have checked the pad alarm, but the pad alarm was not sounding when RN 2 entered Resident 1's room after the fall. RN 2 stated when LVN 3 did not check the bed pad alarm, he (LVN 3) did not notify her (RN 2) that Resident 1 was confused and attempted to get out of bed and did not provide further assistance to Companion 1. RN 2 stated Resident 1 had a preventable fall that resulted in injury. RN 2 stated that the facility's procedure for a resident who has experienced a fall is to keep the resident in the same location and position until the registered nurse evaluates the situation and determines it is safe to move the resident. RN 2 stated, on 8/26/2025, she (RN 2) entered Resident 1's room and was upset that Resident 1 was placed in bed without a registered nurse assessment. RN 2 stated when she (RN 2) assessed Resident 1 in bed, Resident 1 could not move the right arm and had swelling on the left side of the head. RN 2 stated that she (RN 2) could not rule out the possibility that moving Resident 1 back to bed before a registered nurse assessment might have contributed to further injury to Resident 1. During an interview on 11/7/2025, at 4 p.m., LVN 3 stated that the facility's procedure following a resident fall is to refrain from moving the resident until a registered nurse conducts an assessment. LVN 3 stated the registered nurses (RN) assessment determines if there are other injuries, determines if it is safe to transfer a resident after a fall, and the RN assures safety of the resident during the transfer. LVN 3 stated on 8/26/2025, he (LVN 3) and Companion 1 entered Resident 1's room and found Resident 1 on the floor, face down next to the window. LVN 3 stated he (LVN 3), CNA 3, and another CNA (unidentified) moved Resident 1 from the floor to the bed before RN 2 entered the room and assessed Resident 1. LVN 3 stated RN 2 was upset that LVN 3 moved Resident 1 before RN 2 assessed Resident 1. LVN 3 stated LVN 3 and the CNAs should not have placed Resident 1 in bed without an RN assessment, but they did. During an interview on 11/12/2025 at 8:52 a.m. with FM 1, FM 1 stated, on 8/26/2025, Resident 1 had a fall in the facility resulting in a broken right arm that required surgery. FM 1 stated the physical trauma has left Resident 1 unable to hold the right wrist upright. FM 1 stated Companion 1 was hired to provide companionship for Resident 1 and not to provide care to the resident. During a concurrent interview and record review on 11/12/2025 at 9:23 a.m. with the Director of Nursing (DON), the facility Policies and Procedures (P&Ps) regarding fall prevention, accident / hazard prevention, resident supervision, and licensed nurse's job descriptions were reviewed. The DON stated a family-provided companion is treated more like a visitor in the facility and the facility does not give instructions for resident care to a companion. The DON stated that when a resident has a companion the facility is still responsible for providing all the care, supervision, and interventions to prevent falls. The DON stated when a confused resident is reported or observed repeatedly attempting to get out of bed unassisted, the facility process is to re-orient the resident, the LVN can observe the resident, and then the LVN reports to the RN to further assess the resident. The DON stated when Companion 1 stated to LVN 3 that Resident 1 was getting out of bed, LVN 3 was responsible for providing an intervention. The DON stated LVN 3 should not have just relied on Companion 1 to keep the resident safe. The DON further stated when LVN 3 observed Companion 1 in the hallway on the phone, LVN 3 should have immediately gone to Resident 1, but LVN 3 did not. The DON then stated that the pad alarm prevents falls by alerting staff when a resident shifts weight in the bed. The DON stated the pad alarm can also irritate the resident which may stop them from getting up. The DON stated Resident 1 was a high risk for falls and had a physician's order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 9 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few for a pad alarm. The DON stated the pad alarm should have been turned on and functioning while the resident was in bed even when the companion was at bedside. The DON stated LVN 3, CNA 3, and RN 2 stated the alarm was not functioning at the time of Resident 1's fall. The DON further stated that CNA 3 stated on 8/26/2025 that he (CNA 3) left the bed pad alarm off before the fall and after providing care to Resident 1. The DON stated as a result the bed pad alarm was not functioning when Companion 1 left Resident 1's room. The DON stated the facility P&Ps were not followed when Resident 1's bed pad alarm was not functioning and when LVN 3 did not provide interventions to prevent Resident 1 from falling. The DON stated Resident 1 had an avoidable fall that was the direct cause of Resident 1's injuries. The DON then stated that when a resident falls the RN immediately assesses the resident and the RN decides what interventions are necessary and if the resident can be safely transferred to the bed. The DON stated for example, if there is a possible neck injury, the resident should not be moved. The DON stated it was not within LVN 3's job description and scope of practice to assess Resident 1 and make the decision to move Resident 1 to the bed. The DON stated when LVN 3 did not follow their job description there was the potential to worsen Resident 1's injuries. During a review of the facility P&P titled, Fall Management Program, last reviewed 12/3/2024, the P&P indicated, The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible. The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices (external devices that are designed, made, or adapted to assist a person to perform a particular task) to each resident to prevent avoidable accidents. DEFINITIONS. Accident: Any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Avoidable Accident: An accident which occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Position change alarms: Alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads. Supervision/Adequate Supervision: An intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident During a review of the facility P&P titled, Free of Accident Hazards / Supervision / Devices, last reviewed 12/3/2024, the P&P indicated, The facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. GUIDELINES . 2. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A SYSTEMS APPROACH . 1. Processes in a facility's interdisciplinary systematic approach may include:a. Identification of hazards, including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 10 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few inadequate supervision, and a resident's risks of potentially avoidable accidents in the resident environment;b. Evaluation and analysis of hazards and risks;c. Implementation of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment; andd. Monitoring for effectiveness and modification of interventions when necessary.5. Effective Accident Management identifies environmental hazards, the resident's risk for an avoidable accident, and evaluates the resident's need for supervision. 6. Identifying and addressing risks, including the potential for accidents, includes consideration of the environment, the resident's risk factors, and the need for supervision, care, and assistive devices. Implementation of Interventions .Implementation refers to using specific interventions to try to reduce a resident's risks from hazards in the environment . 1. The process includes communicating the interventions to all relevant staff, assigning responsibility, . documenting interventions, . and ensuring that the interventions are put into action. Supervision . 3. Devices such as position change alarms may help to monitor a resident's movement temporarily, but do not eliminate the need for adequate supervision. Adequate supervision to prevent accidents is enhanced when the facility: l. Accurately assesses a resident and/or the resident environment to determine whether supervision to avoid an accident is necessary; and/or 2. Determines that supervision of the resident was necessary and provides supervision based on the individual resident's assessed needs and the risks identified in the environment. 3. Some factors that may result in resident falls include, but are not limited to: . g. Acute change in condition such as fever, infection, delirium; . h: Medication side effects: . m. functional impairments (difficulty rising from a chair, getting on or off toilet, etc.): . o. Cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decision): . q. Pain; and r. Incontinence. During a review of the facility provided RN Job Description, dated 10/2016, The Job Description indicated the RN Assesses and evaluates the health status of resident / patient and provides care and treatment in accordance with physician orders and standards of practice. Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Supervises LVNs and nursing assistants During a review of the facility provided LVN Job Description, dated 10/2016, The Job Description indicated, The Licensed Vocational Nurse (LVN) is responsible for managing the residents' care plans and supervising resident care activities. Both care management and supervisory responsibilities must be executed in accordance with state and federal regulations and facility policies and procedures. Roles and Responsibilities: . Make daily resident rounds to observe and evaluate the resident's physical and emotional status. Notify attending physician, family, and members of interdisciplinary team when . there is a change in condition. Participate in procedures for reporting hazardous conditions. b. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included traumatic hemorrhage (bleeding caused from sudden injury) of right cerebrum (a part of the brain) without loss of consciousness, Colles' fracture of the right radius (break in the larger bone in the forearm near the wrist, caused by a fall on an outstretched hand), zygomatic (cheekbone) fracture, cognitive communication deficit (communication difficulties caused by underlying impairments such as attention, memory, and problem-solving), and history of falls. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand others and able to make themselves understood. The MDS further indicated the resident required substantial/maximal assistance with upper and lower body dressing, toileting, with bathing, moving from sitting to standing, and chair to bed transfers. The MDS indicated the resident used a bed alarm to monitor resident movement and alert staff when movement was detected. During a review of Resident 2's FRE, dated 10/24/2025, the FRE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 11 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few indicated the resident had a history of one to two falls in the past three months, had balance problems while standing / walking, was regularly incontinent, and was a high risk for falls. During a review of Resident 2's CP titled Bed Alarm: (Resident 2) is at risk for fall and requires the use of a bed alarm due to impaired safety awareness, cognitive impairment and getting out of bed unassisted., initiated 10/25/2025, the CP indicated a goal that the resident would maintain optimal safety by ensuring the bed alarm is used consistently, and that staff respond appropriately to prevent falls. The care plan indicated interventions that included placing a functioning bed alarm on the resident's bed, ensuring it is securely attached and training staff how to properly use the bed alarm. During a review of Resident 2's Physician Orders, the Physician Orders indicated an order to place a pad alarm in bed, monitor for placement and function every shift, dated 10/24/2025. During a concurrent observation and interview on 11/5/2025 at 9:35 a.m., observed Resident 2 lying in bed. Observed the resident with the right arm in a bandage. Resident 2 stated Resident 2 had a fall before coming to the facility. Observe hanging from the right side of the bed, a bed alarm control unit with the cord dangling toward the floor and not connected to the bed alarm pad sensor. Resident 2 then stated Resident 2 had pain. During an observation on 11/5/2025 at 9:37 a.m., observed LVN 4 entered Resident 2's room, stated to Resident 2 that LVN 4 would provide help with the resident's pain, and then exited the room. Observed the pad alarm remained disconnected. During a concurrent observation and interview on 11/5/2025 at 9:39 a.m., LVN 4 and LVN 5 entered Resident 2's room. Resident 2 stated Resident 2 felt a little confused and wanted to speak with FM 2. LVN 4 placed a call to FM 2. LVN 5 then walked to the right side of Resident 2's bed and stated the pad alarm was disconnected. LVN 5 stated the pad alarm should always be connected, and it was not. Observed LVN 5 connected the pad sensor to the cord and heard a loud beep. During a follow-up interview and record review on 11/5/2025 at 9:41 a.m. with LVN 5, LVN 5 reviewed Resident 2's physician orders. LVN 5 stated Resident 2 had a recent history of falls and was a high risk for falls while in the facility. LVN 5 stated Resident 2 had a physician's order for a pad alarm. LVN 5 stated when Resident 2's pad sensor was not connected, the pad alarm was not functioning. LVN 5 stated Resident 2's pad alarm should be checked for functionality every time a staff member enters the room. LVN 5 stated LVN 5 had been in Resident 2's room a couple of times that morning and LVN 5 did not check Resident 2's pad alarm. LVN 5 stated it was LVN 5's mistake for not checking Resident 2's pad alarm. During a concurrent interview and record review on 11/13/2025 at 11:11 a.m. with the DON, the DON reviewed the facility P&Ps regarding fall prevention and accident / hazard prevention. The DON stated Resident 2 is at risk for falls and rounds are completed by staff that include checking the functionality of the pad alarm. The DON stated every time staff enter a resident's room they check the environment for safety. The DON stated a staff member may not know a resident has a pad alarm, so they should assess the environment and check the functionality of the pad alarm when they see it. The DON stated Resident 2's plan of care was not implemented when the pad alarm was not plugged in potentially resulting in an accidental fall resulting in injury to the resident. During a review of the facility P&P titled, Fall Management Program, last reviewed 12/3/2024, The P&P indicated, The facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accident hazards as possible.The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. DEFINITIONS. Accident: Any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Avoidable Accident: An accident which occurred because the facility failed to:. Implement interventions, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 12 of 13 Printed: 05/15/2026 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 555904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident .Position change alarms: Alerting devices intended to monitor a resident's movement. The devices emit an audible signal when the resident moves in a certain way. Types of position change alarms include chair and bed sensor pads . During a review of the facility P&P titled, Free of Accident Hazards / Supervision / Devices, last reviewed 12/3/2024, the P&P indicated, The facility provides an environment that is free from accident hazards over which the facility has control, and each resident receives adequate supervision and assistive devices for eachresident to prevent avoidable accidents. GUIDELINES.2. An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents.A SYSTEMS APPROACH.1. Processes in a facility's interdisciplinary systematic approach may include: . c. Implementation of individualized, resident-centered interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment; . Implementation of Interventions.Implementation refers to using specific interventions to try to reduce a resident's risks from hazards in the environment. 1. The process includes communicating the interventions to all relevant staff, assigning responsibility, . documenting interventions, . and ensuring that the interventions are put into action. Event ID: Facility ID: 555904 If continuation sheet Page 13 of 13