The Ellison John Transitional Care Center

In the surveyor’s words

From the most serious findings on record at The Ellison John Transitional Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 22, 2024

  Based on interview and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) physician, when on [DATE], Resident 1's blood pressure (BP - the measurement of the pressure or force of blood inside your arteries [muscular walled tubes that carries blood from the heart to tissues and organs in the body], normal range less than ,d+[DATE] millimeters of mercury [mmHg - unit of pressure measure]) dropped from ,d+[DATE] mmHg on [DATE] at 7:03 p.m. […]

• Immediate jeopardy, isolatedF600Dec 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from sexual abuse (non-consensual [not agreed by the people involved] sexual contact of any type with a resident) on 12/4/2023 at 8:10 a.m. when Resident 1 sat on Resident 2 ' s bed and touched Resident 2 ' s genitals (the sexual organs; the testicles and penis of a male) while Resident 2 laid in bed as observed by Certified Nursing Assistant 1 (CNA 1) and as communicated by Resident 2. This deficient practice resulted in Resident 2 experiencing non-consensual sexual contact from Resident 1 while under the care of the facility. […]

• Immediate jeopardy, isolatedF760Dec 17, 2023

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 11), who was not prescribed (ordered) an intravenous (IV, given through the vein [blood vessels forming part of the blood circulation system]) medication, was on hospice care (focuses on comfort care when the person is approaching the end of life), and was not wearing an identification (ID) wristband (a band worn by residents that contains important resident data [such as name, date of birth, medical record number, and facility name], allowing residents to be identified). […]

• Immediate jeopardy, isolatedF600Jul 16, 2022

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1), who was unable to walk, was incontinent (unable to voluntarily control) of bowel and bladder functions, and was dependent on staff for activities of daily living (ADLs, such as bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene), was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress). […]

• Immediate jeopardy, isolatedF622Jul 16, 2022

  Based on interview and record review the facility failed to permit one of five sampled (Resident 1) to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary and appropriate (needs could not be met at the facility, for safety of the resident or others, the resident no longer needs the services provided by the facility, or lack of payment) and failed to ensure the physician documented in Resident 1 ' s clinical record the basis of the transfer as per facility ' s policy on Transfer and Discharge. […]