Health inspection·December 26, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication errors when the facility failed to: 1. 1. Administer amlodipine besylate (a calcium channel blocker, that works by relaxing and widening your blood vessels) 5 milligrams (mg- a unit of measurement) on 12/15/2025 as ordered. 2. 2. Administer 14 medications as prescribed on 12/17/2025. These deficient practices had the potential to negatively affect Resident 1. Findings:During a review of Resident 1's admission Record (AR), the AR indicates the facility admitted Resident 1 on 11/5/2017 with diagnoses that included vascular dementia (cognitive decline [memory, thinking, judgment] caused by damaged blood vessels in the brain, depriving it of oxygen, often from strokes or chronic conditions like high blood pressure, leading to issues with planning, attention, reasoning, and mood changes), hyperlipidemia (Hyperlipidemia means your blood has too many lipids, or fats, such as cholesterol and triglycerides ), hypertensive heart disease (when long-term, uncontrolled high blood pressure [hypertension] damages your heart, forcing it to work much harder, which makes the heart muscle thicken and stiffen over time, eventually leading to problems like heart failure, heart attack, or stroke), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis following cerebral infarction (when part of your brain tissue dies because blood flow gets blocked, cutting off oxygen and nutrients) affecting left non-dominant side. During a review of Resident 1's Order Summary Report, dated 12/4/2024, the Order Summary Report indicated the following: - Aspirin tablet 81 mg give one tablet by mouth one time a day for cerebral vascular accident (a loss of blood flow to part of the brain, which damages brain tissue ) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). - Calcium Carbonate Vitamin D3 tablet 600-400 mg unit give one tablet by mouth one time a day for supplement - Folic Acid tablet 1 mg give one tablet by mouth one time a day for supplement. - Ginkgo biloba oral tablet 60 mg give one tablet by mouth in the morning for memory loss- Selenium tablet 200 micrograms (mcg- a unit of measurement) give one tablet my mouth one time a day for supplement.- Fish oil capsule 500 mg give 2 capsules by mouth two times a day for supplement. During a review of Resident 1's Order Summary Report, dated 1/24/2025, the Order Summary Report indicated the following Amlodipine Besylate tablet 5 mg give one time a day for elevated blood pressure hold for systolic blood pressure (SBP-the top number in a blood pressure reading, measuring the force of blood against your artery walls when your heart contracts [beats] and pushes blood out) less than 120 diastolic blood pressure (DBP- the second [bottom/lower] number, measures the pressure your blood is pushing against your artery walls while the heart muscle rests between beats) less than 60 or hear rate (HR-the number of heartbeats per unit of time) and call the medical doctor (MD). Call MD if blood pressure (BP-the force of your blood pushing against your artery walls as your heart pumps it through your body) Page 1 of 3 555904 555904 12/26/2025 The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication are held for one week and if SBP is greater than 140 continuously for one week During a review of Resident 1's Order Summary Report, dated 2/13/2025, the Order Summary Report indicated the following CoQ10 Oral capsule 100 mg give one capsule by mouth one time a day for hyperlipemia. During a review of Resident 1's Order Summary Report, dated 2/28/2025, the Order Summary Report indicated the following Keppra Solution 100 mg per milliliters (ml- a unit of measurement) give 5 ml by mouth two times a day for seizures During a review of Resident 1's Order Summary Report, dated 3/12/2025, the Order Summary Report indicated the following Ritalin oral tablet 10 mg give 10 mg by mouth one time a day for excess sleeping. During a review of Resident 1's Order Summary Report, dated 4/18/2025, the Order Summary Report indicated the following Multivitamin-Mineral oral tablet give one tablet by mouth one time a day for supplement. During a review of Resident 1's Order Summary Report, dated 4/19/2025, the Order Summary Report indicated the following Memantine HCI oral tablet 10 mg give one tablet by mouth two times a day for dementia. During a review of Resident 1's Order Summary Report, dated 6/1/2025, the Order Summary Report indicated the following Colace Oral capsule 100 mg give one capsule by mouth one time a day for bowel management hold for loose stools During a review of Resident 1's Order Summary Report, dated 10/30/2025, the Order Summary Report indicated the following Glycolax powder give 17 grams by mouth one time a day for constipation, hold for loose stools give with ounces of water. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 12/15/2025, the MAR indicated amlodipine besylate tablet 5 mg give one tablet by mouth one time a day for elevated BP hold for SBP less than 120 DBP less than 60 or heart rate less than 60. The MAR indicated Resident 1's blood pressure was 108/62 with a heart rate of 78, and medication was administered. During a review of Resident 1's MAR dated 12/17/2025, the MAR indicated the following:- Amlodipine besylate tablet 5 mg give one tablet by mouth, one time a day, for elevated BP, hold for SBP less than 120 DBP less than 60 or heart rate less than 60 was not given on 12/17/2025 at 9 a.m.- Aspiring tablet 81 mg, give one tablet by mouth, one time a day for cerebral vascular accident prophylaxis, was not given on 12/17/2025 at 9 a.m. - Calcium Carbonate Vitamin D3 tablet 600-400 mg unit, give one tablet by mouth, one time a day for supplement, was not given on 12/17/2025 at 9 a .m. - Colace Oral capsule 100 mg, give one capsule by mouth, one time a day for bowel management, hold for loose stools, was not given on 12/17/2025 at 9 a.m. - CoQ10 Oral capsule 100 mg, give one capsule by mouth, one time a day for hyperlipemia, was not given on 12/17/2025 at 9 a.m.Folic Acid tablet 1 mg, give one tablet by mouth, one time a day for supplement, was not given on 12/17/2025 at 9 a.m.- Ginkgo biloba oral tablet 60 mg, give one tablet by mouth in the morning for memory loss, was not given on 12/17/2025 at 9 a.m.- Glycolax powder give 17 grams by mouth, one time a day for constipation, hold for loose stools, give with ounces of water, was not given on 12/17/2025 at 9 a.m.Multivitamin-Mineral oral tablet, give one tablet by mouth one time a day for supplement, was not given on 12/17/2025 at 9 a.m.- Ritalin oral tablet 10 mg, give 10 mg by mouth one time a day, for excess sleeping was not given, on 12/17/2025 at 9 a.m.- Selenium tablet 200 micrograms (mcg- a unit of measurement), give one tablet my mouth one time a day, for supplement was not given on 12/17/2025 at 9 a.m.- Fish oil capsule 500 mg, give 2 capsules by mouth two times a day for supplement, was not given on 12/17/2025 at 9 a.m.- Keppra Solution 100 mg/ml, give 5 ml by mouth two times a day for seizures, was not given on 12/17/2025 at 9 a.m.- Memantine HCI oral tablet 10 mg, give one tablet by mouth, two times a day for dementia, was not given on 12/17/2025 at 9 a.m. During an interview and record review on 555904 Page 2 of 3 555904 12/26/2025 The Ellison John Transitional Care Center 43830 10th Street West Lancaster, CA 93534

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12/26/2025 of Resident 1's December MAR with the Infection Control Preventionist (IP), the IP reviewed Resident 1's December MAR and stated Resident 1's 9 a.m. medications are not signed off. It appears the medications were not given. The IP stated there should be some documentation about why Resident 1 did not take his medication. The IP stated Resident 1 not getting his medications, as prescribed can increase Resident 1's blood pressure and if blood thinners, it can result in developing a blood clot. The IP stated if Resident 1 is having a difficult time swallowing the medication or is refusing medications, the doctor must be notified. If the doctor is not notified it can be a potential delay in care. The IP reviewed Resident 1's MAR and stated for amlodipine parameters it indicates to hold if the SBP is less than 120 or if the DBP is less than 60 or if the HR is less than 60. The IP stated on 12/15/2025 Resident 1's BP was 108/62 and heart rate was 78. The IP stated the nurse administered the medication outside of the parameters. The IP stated if the medication is given outside of the parameters the resident can become hypotensive. During a review of the Facility Policy and Procedure (P&P) titled, Medication Administration-General Guidelines, last reviewed on 12/10/2025, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices.B. Administration 2. Medications are administered in accordance with the written orders of the attending physician.10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medication are administered according to the established medication administration schedule for the facility. 555904 Page 3 of 3