Health inspection·December 1, 2025

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: 555904 If continuation sheet Page 2 of 11 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 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for two of three sampled residents (Residents 1 and 2) by failing to: 1. Administer medications to Resident 1 as ordered by the physician. 2. Provide Resident 1 with the correct size of incontinent briefs (a type of absorbent undergarment, essentially an adult diaper with adjustable tabs, designed for individuals who experience incontinence). 3. Notify Resident 2's physician regarding lack of peripheral intravenous (PIV catheter- a thin, flexible plastic tube inserted into a vein to deliver fluids, medications, blood, or nutrition, using a needle for placement that's then removed, leaving just the tube) access and missed Ertapenem Sodium Injection Solution (antibiotics-medication to treat bacterial infection administered as an intravenous solution) doses. These deficient practices had had the potential to delay care for Residents 1 and 2, negatively affecting Residents 1 and 2's well-being. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses including nontraumatic intracerebral hemorrhage (bleeding within the brain tissue that is not caused by a head injury), diabetes mellitus type two (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases often due to increased pressure inside the eye, leading to irreversible vision loss and blindness if untreated). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 11/11/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1's vision was highly impaired. The MDS indicated Resident 1 frequently incontinent of bladder and bowel. The MDS indicated Resident 1 required maximal assistance (helper does more than half of the effort) from the facility staff for personal hygiene, toileting hygiene, showers, and lower body dressing. a.1. During a review of Resident 1's Care Plan (not titled), initiated on 11/4/2025, the Care plan indicated Resident 1 had impaired visual functioning. The Care Plan interventions indicated to administer Resident 1's eye drops as ordered by the physician. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: -11/4/2025: Brimonidine Tartrate Ophthalmic Solution (an eye drop used primarily to lower high pressure inside the eye from glaucoma, and for redness from minor irritation) 0.2 percent (%-unit of measurement). Instill one drop in both eyes twice a day for glaucoma. -11/4/2025: Dorzolamide Hydrochloride-Timolol Ophthalmic Solution (an eye drop used to lower high pressure inside the eye, treating glaucoma, and preventing vision loss by reducing fluid production in the eye) 2-0.5%. Instill one drop in both eyes two times a day for glaucoma. -11/10/2025: Brimonidine Tartrate Ophthalmic Solution 0.2%. Instill one drop in both eyes three times a day for glaucoma. During a concurrent interview and record review on 12/1/2025 at 3:20 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Audit Report (MAAR), dated 11/2025 was reviewed. The MAAR indicated Dorzolamide Hydrochloride-Timolol Ophthalmic Solution and Brimonidine Tartrate Ophthalmic Solution were administered as follows:Dorzolamide Hydrochloride-Timolol Ophthalmic Solution-11/5/2025: scheduled time: 9 a.m.-administration time 2:37 p.m.11/12/2025: scheduled time 9 a.m. -administration time 11:04 a.m.11/15/2025: scheduled time 9 a.m. -administration time 11:52 a.m. Brimonidine Tartrate Ophthalmic Solution-11/5/2025: scheduled time 9 a.m.-administration time 2:37 p.m. -11/12/2025: scheduled time 9 a.m.-administration time 11:04 a.m. The DON stated Resident 1's medications should have been Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 3 of 11 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administered at the correct time as ordered by the physician. The DON stated Resident 1's treatment was delayed, and Resident 1 had the potential to experience discomfort. 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. 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 medication 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.g. Administration time error: Facility administers to the resident a medication dose greater than sixty (60) minutes from its scheduled administration time or if administration exceeds the time in relation to meals. a.2. During a review of Resident 1's Care Plan (not titled), initiated on 11/4/2025, the Care Plan indicated Resident 1 had a bowel and bladder incontinence (the involuntary loss of bladder (urinary incontinence) or bowel (fecal incontinence) control) and requires extensive assistance with toileting needs. The Care Plan interventions indicated to promote resident dignity, self-esteem during care and use absorbent briefs as indicated. During a concurrent observation and interview on 11/26/2025 at 11:03 a.m. with Certified Nurse Assistant (CNA) 1 in Hallway 1, clean linen cart with different colored incontinent briefs was observed. CNA 1 stated the yellow-colored incontinent briefs are size large (L), green colored incontinent briefs are size extra-large (XL), and the white incontinent briefs are size double extra-large (XXL). During an interview on 12/1/2025 at 2:10 p.m. with Resident 1, Resident 1 stated on the last night of her stay in the facility (cannot recall exact date and time), she (Resident 1) asked facility to provide her XXL incontinent briefs (white) since the other sizes were uncomfortable and tight. Resident 1 stated the facility staff told her that the facility did not have available XXL incontinent briefs in the facility. Resident 1 stated she (Resident 1) called Family Member (FM) 1 to bring the correct size of incontinent briefs. During a concurrent interview and record review on 12/1/2025 at 3:20 p.m. with the DON, Resident 1's Progress Note, dated 11/17/2025 was reviewed. The Progress Note indicated on 11/17/2025, at 2:30 a.m. Resident 1 had an episode of incontinence and asked to be provided with green- or white-colored incontinent briefs. The Progress Note indicated the facility staff informed Resident 1 that there were no green or white incontinent briefs available in the central supply and that there were only yellow (yellow) incontinent briefs left. The Progress Note indicated Resident 1 informed facility staff that the yellow incontinent briefs were not comfortable, and she (Resident 1) did not want to urinate. The Progress Note indicated the facility staff informed Resident 1 that the green and white incontinent briefs will be available in 2 hours and that Resident 1 can use the restroom. The Progress Note indicated that while the facility staff were searching for green or white incontinent briefs, Resident 1's Family Member (FM) 1 brought Resident 1's personal incontinent briefs. The DON stated resident care supplies should be readily available for use and residents should not have to wait for a long time to receive appropriate incontinence care. The DON stated Resident 1 was placed at risk of feeling uncomfortable and developing infection and skin problems due to delay of incontinence care. During a review of the facility-provided policy and procedure (P&P) titled, Incontinence, last revised on 12/3/2024, the P&P indicated, To ensure each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal bladder function (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 4 of 11 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 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as possible. To ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible.Guidelines:.8. Interventions and the provision of care should address treating the residents with respect, enhancing dignity and self-worth, and reducing embarrassment and shame in relation to bowel and/or bladder incontinence. b. 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 bladder (a cancerous tumor that develops in the bladder lining and can spread to other parts of the body), and heart failure (a condition where the heart can't 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 MDS, dated [DATE], 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. -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 10:36 a.m. with Licensed Vocational Nuse (LVN) 1, Resident 2's Progress Notes dated 11/6/2025, 11/7/2025 and 11/8/202s were reviewed. The Progress Notes indicated Resident 2 did not have a PIV catheter from 11/6/2025 to 11/8/2025. LVN 1 stated there was no record to indicate that the physician was notified that Resident 2 did not have a PIV catheter and access for antibiotic administration. 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 2's Ertapenem Sodium Injection Solution to demonstrate the medication was administered. The IP stated there was no record to indicate that the facility staff notified the physician regarding Resident 2's PIV catheter access and missing medication doses. The IP stated failure to notify the physician had the potential for Resident 2 to experience complications from unresolved infection. During an interview on 12/1/2025 at 3:20 p.m. with the DON, the DON stated the failure to notify the physician regarding Resident 2's missed antibiotic doses was a disruption of antibiotic therapy and 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, When a medication reaches a resident in error, the facility should:.b. Notify the resident's representative and the Physician/Prescriber to obtain further instructions and/or orders. Omission error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. 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:. 9. Notification of the Physician (if any complications). Reporting:. 2. Report other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 5 of 11 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 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: 555904 If continuation sheet Page 6 of 11 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 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 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were free from significant medication error (means the identified administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards), by failing to: 1. Administer Bisacodyl rectal suppository (a fast-acting stimulant laxative inserted into the rectum used for short-term relief of occasional constipation) to Resident 1 by the correct route. 2. Ensure Resident 2 received full course of Ertapenem Sodium Injection Solution (antibiotics-medication to treat bacterial infection administered as an intravenous solution) as ordered by the physician. These deficient practices had the potential to cause adverse effects (a harmful, unintended, and undesirable response to a medication) and negatively affect Resident 1's and Resident 2's well-being.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/4/2025, with diagnoses including nontraumatic intracerebral hemorrhage (bleeding within the brain tissue that is not caused by a head injury), diabetes mellitus type two (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), and glaucoma (a group of eye diseases often due to increased pressure inside the eye, leading to irreversible vision loss and blindness if untreated). During a review of Resident 1's Care Plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs), initiated on 11/10/2025, the Care plan indicated Resident 1 was at risk for adverse reactions secondary to medication error due to Bisacodyl suppository inserted into the vagina (the internal muscular canal that connects the cervix to the outside of the body.) During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 11/11/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required maximal assistance (helper does more than half of the effort) from the facility staff for personal hygiene, toileting hygiene, showers, and lower body dressing. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order: -11/4/2025: Bisacodyl Rectal Suppository ten milligram (MG-unit of measurement). Insert one suppository rectally every 12 hours as needed for constipation (having infrequent bowel movement with hard, dry stools that are difficult to pass, causing straining and bloating). During a concurrent interview and record review on 12/1/2025 at 3:20 p.m. with the Director of Nursing (DON), Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 11/10/2025 was reviewed. The COC form indicated that during the administration of bisacodyl suppository Resident 1 stated that she (Resident 1) felt that the suppository went into the wrong orifice (opening or hole) and not the anus as indicated. The DON stated the failure to administer a medication by the correct route as ordered by the physician is a medication error. The DON stated the failure to administer Resident 1's suppository by the correct route had the potential to delay treatment and cause pain to Resident 1. b. During a review of Resident '2s admission Record, the admission Record indicated the facility admitted Resident 2 on 10/28/2025, with diagnoses of 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 bladder (a cancerous tumor that develops in the bladder lining and can spread to other parts of the body), and heart failure (a condition where the heart can't pump enough blood to meet the body's needs, causing symptoms like fatigue, shortness of breath, and swelling). During a review of Resident Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 7 of 11 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 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], 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: 555904 If continuation sheet Page 8 of 11 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 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 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain complete blood count with differential (CBC with differential - a blood test that measures red blood cells, white blood cells, and platelets used to help diagnose and monitor many conditions, such as infection, inflammation, and to evaluate the effectiveness of a treatment) blood test as ordered by the physician for one of three sampled residents (Resident 2). This deficient practice had the potential to delay necessary care and services for Resident 2.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 10/28/2025, with diagnoses of 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 can't 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 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 Minimum Data Set, dated [DATE], 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: - 11/14/2025: Repeat CBC with differential one time only for one day. During a review of Resident 2's Progress Note, dated 11/14/2025 at 14:14pm., the Progress Note indicated facility received a call from the laboratory stating that the blood sample collected for Resident 2 was clotted and could not be used for testing. The Progress Note indicated that the physician was notified, an order to repeat blood test was placed and carried out. During an interview on 12/1/2025 at 11:34 a.m. with the Infection Preventionist (IP), the IP stated when laboratory notified the facility that the collected blood specimen was clotted, she (IP) placed a new order for the blood collection on 11/14/2025. The IP stated the following day was a Saturday (11/15/2025) and the laboratory did not notify the facility that the blood would not be collected during the weekend. The IP stated there was no record to indicate the facility followed up with the laboratory after the weekend on 11/17/2025 and 11/18/2025. The IP stated the repeat CBC with differential was not completed for Resident 2. During an interview on 12/1/2025 at 3:20 p.m. with the Director of Nursing (DON), the DON stated the facility staff should have followed up with the laboratory to make sure Resident 2's order for CBC with differential was completed even if the laboratory did not notify the facility of the delay. The DON stated the blood test results were necessary for Resident 2's physician to assess and evaluate Resident 2's infection progress. The DON stated the failure to follow up with Resident 2's physician order for CBC with differential to make sure the test was completed had the potential to delay treatment for Resident 2 and negatively affect Resident 2's well-being. During a review of the facility-provided policy and procedure (P&P) titled, Laboratory Services, last revised on 12/3/2024, the P&P indicated, Laboratory, radiology, or other diagnostic services ordered by the physician will be completed in a timely manner. Guidelines: 1. The facility shall provide or obtain laboratory services, to meet the needs of its residents.3. The facility strives to meet the needs of residents with regard to the quality and or/timeliness of providing laboratory services and reporting laboratory results. During a review of the facility-provided policy and procedure (P&P) titled, Infection Prevention and Control Program, last revised on 12/3/2024, the P&P Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555904 If continuation sheet Page 9 of 11 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 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: 555904 If continuation sheet Page 10 of 11 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 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: 555904 If continuation sheet Page 11 of 11