Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 555904

The Ellison John Transitional Care Center

108 federal citations on record , including 3 at the Immediate Jeopardy level, and 4 federal enforcement actions totaling $189,236.

3 Immediate Jeopardy

Record summary

Federal record · Q1 2026
108
Total citations
93
Last 3 years
5
Actual harm+
4
Federal penalties
$189,236
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care25 Care Planning23 Medication & Pharmacy21 Resident Rights16 Infection Control10

Most common F-tags at this facility

F8809 F7557 F6566 F8426 F6896

Citation history

108 on record
SurveyF-TagViolationSeveritySource
Dec 30, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Dec 26, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Dec 1, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Dec 1, 2025F770Provide timely, quality laboratory services/tests to meet the needs of residents.DComplaint
Dec 1, 2025F760Ensure that residents are free from significant medication errors.EComplaint
Dec 1, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EComplaint
Dec 1, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
Nov 12, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Nov 12, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Nov 12, 2025F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Sep 11, 2025F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.DComplaint
Sep 11, 2025F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Jul 22, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
May 5, 2025F770Provide timely, quality laboratory services/tests to meet the needs of residents.DComplaint
May 5, 2025F692Provide enough food/fluids to maintain a resident's health.DComplaint
Apr 22, 2025F880Provide and implement an infection prevention and control program.DComplaint
Apr 22, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Apr 22, 2025F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.DComplaint
Feb 28, 2025F880Provide and implement an infection prevention and control program.DComplaint
Feb 28, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Feb 28, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Feb 28, 2025F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.DStandard
Feb 28, 2025F791Provide or obtain dental services for each resident.DStandard
Feb 28, 2025F760Ensure that residents are free from significant medication errors.EStandard
Feb 28, 2025F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EStandard
Feb 28, 2025F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Feb 28, 2025F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Feb 28, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EStandard
Feb 28, 2025F697Provide safe, appropriate pain management for a resident who requires such services.DStandard
Feb 28, 2025F695Provide safe and appropriate respiratory care for a resident when needed.EStandard
Feb 28, 2025F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Feb 28, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EStandard
Feb 28, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Feb 28, 2025F658Ensure services provided by the nursing facility meet professional standards of quality.EStandard
Feb 28, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Feb 28, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Feb 28, 2025F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard
Feb 28, 2025F641Ensure each resident receives an accurate assessment.BStandard
Feb 28, 2025F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.BStandard
Feb 28, 2025F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.DStandard
Feb 28, 2025F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.DStandard
Feb 28, 2025F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
Feb 21, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Jan 15, 2025F880Provide and implement an infection prevention and control program.EComplaint
Dec 23, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Dec 23, 2024F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.DComplaint
Dec 23, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
Dec 5, 2024F880Provide and implement an infection prevention and control program.EComplaint
Nov 22, 2024F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.DComplaint
Nov 22, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.DComplaint
Nov 22, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.JComplaint
Nov 20, 2024F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.EComplaint
Jul 26, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
Feb 23, 2024F880Provide and implement an infection prevention and control program.EStandard
Feb 23, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Feb 23, 2024F760Ensure that residents are free from significant medication errors.EStandard
Feb 23, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EStandard
Feb 23, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.EStandard
Feb 23, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EStandard
Feb 23, 2024F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Feb 23, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EStandard
Feb 23, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Feb 23, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Feb 23, 2024F658Ensure services provided by the nursing facility meet professional standards of quality.EStandard
Feb 23, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Feb 23, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Feb 23, 2024F641Ensure each resident receives an accurate assessment.BStandard
Feb 23, 2024F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.BStandard
Feb 23, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DStandard
Feb 23, 2024F558Reasonably accommodate the needs and preferences of each resident.DStandard
Feb 23, 2024F554Allow residents to self-administer drugs if determined clinically appropriate.DStandard
Feb 23, 2024F552Ensure that residents are fully informed and understand their health status, care and treatments.DStandard
Jan 21, 2024F880Provide and implement an infection prevention and control program.DComplaint
Jan 21, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Jan 21, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Jan 21, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DComplaint
Dec 28, 2023F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.DComplaint
Dec 17, 2023F760Ensure that residents are free from significant medication errors.JComplaint
Dec 17, 2023F610Respond appropriately to all alleged violations.DComplaint
Dec 17, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.JComplaint
Dec 17, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Nov 16, 2023F880Provide and implement an infection prevention and control program.EComplaint
Sep 19, 2023F881Implement a program that monitors antibiotic use.DComplaint
Aug 31, 2023F880Provide and implement an infection prevention and control program.DComplaint
Aug 15, 2023F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DComplaint
Aug 15, 2023F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Aug 15, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Aug 15, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EComplaint
Aug 15, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Aug 15, 2023F554Allow residents to self-administer drugs if determined clinically appropriate.DComplaint
Jul 7, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Jun 8, 2023F658Ensure services provided by the nursing facility meet professional standards of quality.DComplaint
Apr 30, 2023F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.DComplaint
Feb 3, 2023F880Provide and implement an infection prevention and control program.DStandard
Feb 3, 2023F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Feb 3, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Feb 3, 2023F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EStandard
Feb 3, 2023F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DStandard
Feb 3, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Feb 3, 2023F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EStandard

Federal enforcement history

Federal regulators have imposed 4 enforcement actions against this facility, including 2 civil money penalties totaling $189,236 and 2 payment-denial actions spanning 21 days.

DateTypeFinePayment denial
Nov 20, 2024Fine$125,220—
Nov 20, 2024Payment Denial—Dec 24, 2024 · 17 days
Dec 17, 2023Fine$64,016—
Dec 17, 2023Payment Denial—Jan 17, 2024 · 4 days
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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